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No. 

Boston 

Medical Library 

Association, 

ig BOYLSTON PLACE 



I 




EEPOET 

OP A 

COMMITTEE APPOINTED BY THE 

aiNICAL SOCIETY OF LONDON 

TO IKVBeTIOATB THE 




CERTAm^HtS^Tl^^^SEASBS. 
SUPPLEMENT TO VOWJME THE TWENTT-ITPTH. 



LONDON ! 
LONGMANS, GREEN, AND CO. 



AUG 25 1898 



CONTENTS 





•• , 






FAGB 


iNTHODVcnovr • . . > . . . . V 


List of Committbb 






1 1 






X 


DiFHTHEBIA • 






• 






1 


Entebio Fbybb 












. 55 


Influenza 












. 78 


Measles 












88 


MUHFS 












. 107 


Rubeola 












. 120 


ScABLET Fbybb 






• i 






, 131 


Smallfox 












178 


Yabicella 












212 


WnooFiNa-coueH 












219 



INTRODUCTION. 



-•O*" 



IN 1878 the Clinical Society of London appointed a Com- 
mittee to investigate the periods of incubation and con- 
tagioasness of smallpox^ scarlet f ever^ typhas f ever^ diphtheria^ 
enteric f ever^ erysipelas^ varicella^ mumps^ and other commu- 
nicable diseases. The subject had been brought to the notice 
of the Society by the late Dr. Murchison in a paper entitled 
" Observations on the Period of Incubation of Scarlet Fever, 
and of some other Diseases ** {Transactions, vol. xi, p. 238). 

In response to a circular then issued a certain amount of 
valuable material was received by the Committee^ but it was 
thought desirable to defer the presentation of any report until 
further experience was available. 

In November, 1888, the Conmiittee was reconstituted^ and a 
new circular letter was prepared, asking for particulars of 
cases which might throw light on the pei*iods of incubation or 
of contagiousness of the zymotic diseases commonly observed 
in the United Kingdom. This letter was sent to many medical 
officers of health, as well as to a number of gentlemen practising 
in the more sparsely populated parts of the country, who it 
was thought, in view of their remoteness from large centres of 
population, might have peculiarly favorable opportunities of 
tracing the source and progress of infection. The letter was 
also published in the medical journals. 

A large number of replies were received in response to this 
second letter, and in addition thereto Sir George Buchanan 
allowed his complete collection of reports made to the Medical 
Department of the Local Government Board since 1878 to be 
examined ; extracts from reports of earlier date had already 
been made by Sir G. Buchanan himself. The material thus 
obtained has been arranged, condensed, and tabulated in the 
following pages. Every case which appeared in any way to 
throw light on the points which the Committee was appointed 



vi Introduction, 

to investigate has been reproduced^ as far as possible in the 
writer's own words. 

The diseases as to wbich the Committee finds itself in a 
position to report are the following: — Smallpox^ varicella, 
measles, rubeola, scarlet fever, influenza, whooping-cough, 
diphtheria, enteric fever, mumps. 

A separate section is devoted to each disease. For conve- 
nience of reference the sections are not arranged in the above 
natural order, but in alphabetical sequence. 

The majority of the cases contained in the report are new. 
Inafewinstieincesthe histories had beenpublishedin the medical 
journals orelsewherebefore being sent to theCommittee ; many 
of those received from medical officers of health had been pub- 
lished in their annual reports, which, however, are not docu- 
ments easily available for reference. Most of the cases reported 
to the Local Government Board have been published in its 
special reports, and a few in the Annual Reports of the Medical 
Officer. It must, however, be clearly understood that there 
has been no attempt to collect the published literature of the 
subject. On the contrary, it was the desire of the Committee 
to bring forward original matter for the elucidation of a 
subject of considerable practical importance. The introduc- 
tion prefixed to each section contains a summary of the cases, 
and is founded entirely on the histories communicated to the 
Committee, with the addition of the cases reported to the 
Society by Dr. Murchison in the paper which originally led to 
the appointment of the first committee. The histories are, it 
is believed, given with sufficient fulness to enable the reader 
to form his own estimate of the value of the evidence adduced 
in each case. In the introduction to each section an attempt 
is made to indicate the relative value of this evidence. 

As was inevitable from the method followed, the amount and 
character of the material to be dealt with in respect of each 
disease varied very greatly. Thus under diphtheria and 
scarlet fever, for instance, the histories received are probably 
superior not only in number, but in value, to any which exist 
elsewhere; whereas in certain other diseases — as, for example, 
whooping-cough — the number of cases sent in was small, and 
the histories not very conclusive. 

The term " period of incubation ^^ has been taken in its 
ordinary sense, to mean the interval between exposure to a 
source of infection, and development of the earliest recognis- 
able symptoms. During this interval the most careful clinical 
examination commonly fails to reveal any departure from the 



Introduction. vii 

standard of healthy but this is not always so. The occurrence of 
ill-defined signs of illness before the onset of the characteristic 
symptoms sometimes renders it extremely difficult to settle 
with precision the date at which the di^ase should be reckoned 
to have begun. In enteric fever, for instance, complaint is 
sometimes made of malaise and other indefinite subjective sym- 
ptoms for some days before the onset of recognisable signs ; 
again, in measles a fugitive initial fever may sometimes be 
noted, while in diphtheria it probably happens not infre- 
quently that the specific infection is preceded by & non- 
specific inflammatory disorder of the throat. The special pos- 
sibilities of error from such sources are discussed under the 
head of each disease. 

Trousseau,*^ in a well-known passage in his lectures, said : 

" Nothing is more difficult than to state the exact time at which con- 
tagion has l^n contracted in an exanthematons fever, when the viras 
has not been directly introduced by inoculation. . . . According to some 
the incubation of scarlatina varies in duration from three to nve days, 
according to others it lasts for eight days, and some believe that it may 
be prolonged to fifteen, twenty, or even thirty^ days. In fact, the 
figures given have been hypothetical. There exists an unwillingness 
to admit the fact that it is impossible to determine the duration of the 
period of incubation, just because it is impossible to fix the date of its 
commencement." 

This objection, as he himself admits elsewhere by implica- 
tion, does not apply to cases in which the evidence shows that 
the person infected was exposed to the source of infection for 
a few minutes or hours only. Such cases, therefore, possess 
a special value, and in the following pages have been 
arranged in special tables and discussed separately, when 
their number warranted such a course. They have been, in 
fact, made the basis of the conclusions drawn as to the dura- 
tion of incubation, while other histories, in which only the 
date of the commencement or cessation of exposure to a 
source of infection was given, have been used for contributory 
evidence. A case in which exposure has been prolonged, 
but in which the date of the commencement of symptoms is 
known, may afEord evidence of a period of incubation unusu- 
ally short ; while a case in which the exposure was continuous 
down to a certain date, but ceased at that date, may furnish 
an example of an incubation period unusually long.f It 

* New Syd. Soc. translation, vol. ii, p. 163, et seq. 

t It may possibly be objected that too much space and importance has been 
given to the evidence afforded in the case of certain diseases by the history of 
school epidemics. While it is true that the gathering together in a school of a 



viii Introduction, 

Bhonld be notedj however^ that in certain diseases — in diph- 
theria^ for instance^ and perhaps in measles — there is some 
evidence that continuous^ i. e. prolonged exposure to a source 
of infection appears to tend to shorten the period of incuba- 
tion.* The cognate suggestion^ that the period of incubation 
in enteric fever is shorter when the "dose" of infective 
material introduced into the system is larger^ has also been 
noted; but ground sufficient for a full discussion of these 
points, which are perhaps rather of theoretical interest than 
practical importance, is wanting in the cases communicated to 
the Committee. 

In the calculation of percentages, which has been done in 
most cases as a matter of convenience, the nearest whole 
number has been taken. The adjective " diphtherial '^ has 
been systematically used to express the specific process due 
to the disease diphtheria, the term diphtheritic being used 
for other inflammatory processes not due to true diphtheria.t 
This statement does not, however, apply to quotations within 
inverted commas. 

The Committee is much indebted to the numerous gentle- 
men who have contributed cases and reports, and who have 
in many instances been at no little trouble to verify all the 
circumstances, and to answer inquiries addressed to them 
when additional particulars were desired. 

The Committee has especially also to' thank Dr. Clement 
Dukes, who read the proofs of the sections dealing with 
Mumps and German Measles, and Dr. Birdwood, the Medical 
Superintendent of the Smallpox Hospital ships of the Metro- 

large number of insoeptible individnalg, with many opportnnities of interoom- 
mnnication, is a source of possible error of observation, yet in a large public 
school, with a good sanatorium and a vigilant medical officer, a case is generally 
recognised at the earliest possible stage, and isolation and disinfection are carried 
out with great care. In consequence it frequently happens, at any rate in smaller, 
or at the beginning of more serious epidemics, that the interval between the 
cessation of exposure and the onset of symptoms can be determined with great 
accuracy. 

• Dr. Birdwood (Ou^9 Hospital JEteporU, xlviii, p. 102), on the other hand, 
believes, *' that length of exposure to infection has a great deal to do with the 
severity or mildness *' of an attack of smallpox, but does not aifect the duration 
of the period of incubation. He brings forward evidence to show that ** suc- 
cessive sowings of spores result in successive crops of pocks. If some patients 
happen to have been exposed for a short time only, the eruption on that 
particular part will all, or almost all, appear on one day. If others are exposed 
from day to day, crops of pocks continue to come out for three or four days." 

t This restriction of the terms is in accordance with a suggestion made by 
Dr. Donald Macalister (Practitioner, vol. xliii, p. 123). Its general adoption 
would undoubtedly avoid much ambiguity. 



Introduction^ 



IX 



politan Asylums Board, for a like kind service in respect of 
the section on Smallpox. 

The Report has been prepared for publication by Dr. 
Dawson Williams, one of the Honorary Secretaries of the 
Committee. 

Note hy Dr. Broadbent. — The Committee are bound as a 
simple matter of justice to call attention to the important part 
which Dr. Dawson Williams has taken in collating, sifting, 
and arranging the large amount of material embodied in the 
Report. It is due mainly to the enthusiastic interest he has 
taken in the question, and to the labour he has devoted to the 
investigation, that the Report can now be placed before the 
Society, and the Committee consider that he deserves the 
special thanks of the Society. 



COMMITTEE. 



The members of the Committee, as reconstituted in 1888, were — 



W. H. BROADBENT, M.D., Chairman. 



SIR GEORGE BUCHANAN, M.D. 
WILLUM CAYLEY, M.D. 
THOMAS BARLOW, M.D. 
ALFRED HILL, M.D. 



ISAMBARD OWEN, M.D. 
R. THO RNE THORNE, M. B., C.B. 
ALDER SMITH. 
R. W. PARKER. 



Honorary Secretaries. 
SHIRLEY F. MURPHY. | DAWSON WILLIAMS, M.D. 




REPORT. 



DIPHTHERIA. 

IN attempting to ascertain the periods of incubation and 
infectiousness in diphtheria certain special diflSculties are 
encountered, or rather certain difficulties which exist in the 
cases of several other infectious diseases are found to be 
specially great. In the first place, it is not always possible to 
fix the exact time at which the specific process begins. In 
the second place, in certain epidemics of diphtheria a large 
proportion of the cases are of so mild a character that the 
disorder is considered to be ^^ simple sore throat.*' Among the 
notes and reports which follow are many instances in which 
an epidemic of diphtheria has been started or kept up by 
cases so mild that medical advice was not sought, or so ano- 
malous that, in their earlier stages at least, a correct diagnosis 
was impossible, or was not made. For this reason, cases which 
appear to show that the incubation period of diphtheria may 
be prolonged very much beyond that which the bulk of the 
returns show to be the average ought to be very care- 
fully scrutinised. In the third place, the fact, now well 
established, that diphtheria may be conveyed by milk has to 
be constantly borne in mind.* From this last source of error, 
however, the reports made to the Local Government Board, 
and communicated to the Committee by Sir George Buchanan^ 
are, as a rule, free. 

Incubation Period. 

If the cases in which the disease is stated to have been 
contracted by a single exposure to infection for a definite 
short period (see Table I) be first considered, it will be seen 
that in 17, or 63 per cent., the period of incubation was four 
days or less, and that in all but one it was seven days or less. 

In twenty-three instances the exposure to the source of 

* See Mr. Power's concluding remarks in Report xxxix. 

A 



2 Diphtheria. 

infection ceased on a given date ; it will be seen from Table 

II that the interval between the cessation of exposure to in- 
fection and the development of the disease was in eleven 
instances, or 48 per cent., four days or less, and in eighteen, or 
78 per cent., seven days or less. 

In twenty-one instances the infected person was exposed to 
infection at and after a given date. It will be seen from Table 

III that the period from the commencement of the exposure 
to the development of the disease was four days or less in 
eleven cases, or 52 per cent., and was seven days or less in 
seventeen, or 81 per cent. 

Combining Tables I and III, we have 48 cases in which 
the dates at which exposure to infection commenced, and the 
disease commenced, are known. The periods of incubation 
in this series of 48 cases cannot have exceeded the intervals 
between the two dates above defined, though in a certain por- 
tion, viz. the 21 cases in Table III, they may have been less. 
It will be seen that in 28, or 58 per cent., the period of incu- 
bation cannot have exceeded four days ; while in 43, or 90 
per cent., it cannot have exceeded seven days. In 4 other 
cases, viz. Nos. 9, 24, 51, 13 (Table II), the dates at which 
exposure to infection commenced, and the disease commenced, 
are also known ; adding these to the 48 previously mentioned 
in this paragraph, we have 52 cases in which the periods of 
incubation cannot have exceeded the intervals between these 
two dates. In 30, or 58 per cent., the period of incubation 
cannot have been more than four days ; while in 45, or 87 
per cent., it cannot have been more than seven days. 

These figures point strongly to the conclusion that the 
period of incubation in diphtheria comparatively seldom ex- 
ceeds 7 days. 

In Table IV are brought together all the cases in 
Tables I, II, and III which best stand the test of criticism ; 
that is to say, the statements as to the date and other circum- 
stances of infection may probably in these 32 cases be 
accepted as accurate. In these cases the period of incubation 
cannot have exceeded four days in 16, or 50 per cent., and 
cannot have exceeded seven days in 27, or 84 per cent. 

If the instances in which the period of incubation is 
believed to have been prolonged considerably beyond seven 
days are separately examined, it will be seen that in none is 
the evidence entirely conclusive. In Case 72 (Report xlvi) 
Dr. Parsons merely says that ^^ it was locally believed that 
the period of incubation was fourteen days.^' He is unable to 



Diphtheria. 3 

give the dates^ and evidently does not himself attach much 
importance to the case. 

In Case 10 (Report iv) Dr. Ogle is only able to give the 
mother^s " most positive *' statement that the child^s illness 
commenced eleven days after the last exposure. In Cases 17 
and 18^ children discharged from a hospital in which diphtheria 
was prevalent were attacked nine and fourteen days respec- 
tively after leaving the hospital. It does not, however, appear 
to have been proved that they were not exposed to infection 
from some other source in their own homes or elsewhere. In 
Case 3, reported by Dr. Bruce Low, the suggested period of 
incubation — ^five weeks all but two days — is so exceptional, that 
it is doubtful whether it ought to be accepted in the absence 
of any evidence from other cases of periods even approximat- 
ing to thirty-three days. The infection can be preserved in 
fomites, and it is not impossible that it may have been so 
preserved in this case in clothes which were only taken into 
use when the w;eather became colder. 

The relative frequency with which the disease began, after 
a single exposure, on each day from the 2nd to the 7th may 
be exhibited in the following rough table, in which the tabular 
numbers of the cases are arranged under the various days. 



19 • 












25 












32 












36 




23 








37 


41 


29 








52 


30 


21 


83 


46 


^ 


54 


45 


51 


31 


47 


r2 


74 


77 


75 


69 


64 


65 



Second. Third. Fourth. Fifth. Sixth. Seventh. 

Dr. Murchison does not give any cases throwing light on the 
period of incubation in this disease, but quotes Oertel to the 
effect that " it may be stated positively to occupy from two to 
five days." The cases above tabulated appear to show that the 
period of incubation is most commonly two days, that it is not 
infrequently three or four days, and that it is sometimes ex- 
tended to six or seven. The evidence for a latent period 
beyond seven days is in no case conclusive, and if such an ex- 
tension does ever occur it must be only in rare instances. 
That the period does vary, even when all the circumstances 
are very similar or nearly identical, appears from several 
of the reports quoted below ; the most striking instance is the 
occurrence reported by Dr. Parsons (lii). 



4 



Diphtheria. 



Table I. — In the following cases there is evidence that the 
disease was contracted by a single short eocposure. 



No. of 


No. of 


Period of 




CMC. 

19 


report. 


iuenbation. 




• • 

Vll 


2 days 


Possibility of previous exposure does not seem to have 








been entirely eliminated. 


25 


• • 

Xll 


»f 


History not incompatible with a long period, i.e, 11 
days at least. 


30 


xvi 


57 honrs 




32 


xvii 


2 days 


Possibility of previous exposure not entirely eliminated, 
but the cases lived in different hamlets. 


38 


• •• 

XVlll 


" } 


Possibility of previous exposure not entirely elimi- 


39 


• •• 

XVlll 


nated. 


53 


xxix 


99 


Dates are not stated ; information obtained some time 
after occurrences. 


56 


xxxii 


»* 


There had been previous unrecognised cases in the 
town. 


1 76 


lii 


»» 




i 41 

1 


xix 


2 or 3 days 


Dates not stated ; information obtained some months 
after occurrences, but probably approximately cor- 
rect. 


46 


xxi 


3 days 




79 


liii 


*» 


• 


23 


• • 

Xll 


3 to 4 days 




29 


XV 


3 or 4 days 


Dates not given, but statement probably approxi- 
mately correct. 


21 


ix 


4 days 




52 


XXV 


»» 


Possibility of previous exposure not eliminated. His- 
tory compatible with a longer period. 


77 


lii 


if 




31 


xvi 


5 days 




; 71 


xliii 


» 




83 




»» 




47 
48 


• • 


6 days 


Cases doubtful owing to almost simultaneous attack in 


XXll 

• • 

▼▼11 


another member of the family who was not exposed 


AJLU 


>» 


to the assumed source of infection. 


66 


xl 


»» 




49 


• • 

xxu 


7 days 


Same remarks apply as to 47 and 48. 


74 


xlviii 


if 




67 


xl 


If 


Doubtful (?), as source of infection was not certainly 
traced. 


72 


xlvi 


14 days 


Reporter says that it was "locally believed" that in- 
cubation had lasted 14 days. 



Diphtheria. 5 

Table IL — In the following cases exposure to the source of 

infection ceased at a known date. 



• 




Interval between 


Interval between 




No. of 


No. of 


cessation of 


commencement 




cue. 


report. 


exposure and 


of exposure, when 




9 




attack. 


stateo, and attack. 




• •• 
111 


2 days 


4 days 




24 


xu 


>t 


»» 




27 


XV 


3 days 


— 




33 


xvii 


»> 


— 




84 


xvii 


» 


— . 




61 


xxiv 


2 days 


8 days 




13 


V 


8 days 


9 days 




42 


XX 


4 days 


— 


A 


43 


XX 


»» 




• • 


44 


XX 


>* 






81 


lUi 


» 


— 




20 


viii 


5 days 


— 




85 


xvii 


t* 


— 




61 


xxxviii 


7 days 


= } 


Possibility of subsequent exposure not 


62 


XXX viii 


»> 


completely eliminated. 


63 


xl 


>» 


— 




64 


xl 


»> 


— 




82 




n 


— 




78 


liii 


8 days 


"™ 


Doubtful, as communication may have 
subsequently occurred between the 








two sections of the family. 


17 


vi 


9 days 


— ? as to condition at home ; ? f omites. 


10 


iv 


11 days 


— Mother's statement only. 


18 


vi 


14 days 


— 


Dates not given; ? as to condition at 










home ; ? f omites. 


3 




83 days 




? fomites. 



Diphtheria. 



Table III. — Cases in which the individual was exposed to 
infection at and after a known date, showing the number of 
days after the commencement of such exposure at which the 
disease began. 







Interval between 






No. of 


No. of 


commencement of 






case. 


report. 


exposure and 






54 




attack. 






xzxi 


Iday 1 


Infection may have been derived from some other 


55 


XXX L 


unrecognised source. 




50 


• • • 

XXlll 


2 days 






22 


X 


>» 






68 


xlii 


2 or 3 days 






40 


xix 


3 days 






6 


• • 

n 


4 days 






8 


• • 

11 


» 






11 


V 


»f 






80 


liii 


» 


May have been previous exposure. 


45 


xxi 


9» 






14 


vi 


6 days 






26 


XV 


»» 






65 


xl 


»f 






5 


• • 

11 


7 days 






7. 


• • 

11 


» 






70 


xlii 


»» 






28 


XV 


8 days 






12 


V 


9 days 






15 


• 

VI 


13 days 






16 


vi 


14 days 








Table IV. 






Table I. 


Tadle III. 


Table II. 


No.il 


a. Da^s of incuba- 


No. in Days of incnba- 


No. in Daju of incnba- 


schedi 


ile. tion period. 


schedule. tion period. 


schedule. tion period. 


30 


... 3 days less than 


50 ... 2 


9 ... 4 


38 


2 days 


40 


3 


51 ... 8 


39 


... tt 


6 


4 


13 ... 9 


76 


••• tt 


8 


4 




46 


3 


11 


4 




79 


3 


45 


4 




23 


3 or 4 


14 


6 




21 


4 


26 


6 




77 


4 


65 


6 




31 


5 


5 


... 7 




71 


5 


7 


7 




83 


5 


70 


7 




66 


6 


28 


8 




74 


7 


15 


.. 13 












16 


14 





Diphtheria. 7 

DURA.TION OF Infectious Period. 

The cases throwing light on the duration of the period of 
infectiousness have been brought together in the following 
tables. 

Table V contains a number of cases in which the indi- 
vidual who infected others was either convalescent or was 
supposed to have completely recovered. In some instances 
the patient was suffering from paralytic symptoms, in others 
there was sore throat or discharge from the nose, but in 
others the patient is not known to have presented any sym- 
ptoms whatever. Excluding cases of so-called chronic 
diphtheria, it will be seen that the interval between the acute 
attack and the time at which the patient infected others 
varied from a few days to two and a half months. Dr. 
G-resswell has brought forward evidence to show that in 
certain persons a single attack of the disease leaves a peculiar 
liability to suffer from repeated attacks, and that such 
patients during these subsequent attacks are capable of 
infecting others with typical diphtheria ; further, in certain 
cases he believes that such a patient may be infective though 
not obviously suffering from any acute or subacute symptoms. 
In some instances it has even seemed that the power of a 
patient to transmit infection to others went on increasing for 
some week or two after the commencement of convalescence. 
The reports afford evidence also that infection can be derived 
from the body of a person dead of diphtheria (see xxxii, 
xxxvii, and Case 83). 

Table VI contains the cases in which the individual who is 
believed to have infected others was in the incubative or very 
early stage of the developing disease. The cases are few in 
number, and in all, with the exception of Case 23 (xii) and pos- 
sibly of Cases 11 and 12 (v), the patients were already suffering 
from sore throat or were " sickening.*' In one case (Case 37, 
Eeport xviii) it appears that the patient, who was brought into 
contact with eighty-six children of susceptible age four days 
before her attack, was not then infective. In his report on 
an epidemic at Sculcoates (Repoi;t iii) Dr. Blaxall observes that 
it was ^^ noteworthy that the infection would appear to have 
been disseminated by sufferers in the incubative and acute 
stages of the disease;'* and in a report on diphtheria at 
Pamham Mr. R. D. R. Sweeting states that " suspicion of 
early infectiousness of the disease in its pre-exudative stage 
was also afforded.'* 



8 Diphtheria. 

Table V. — Examples of infection conveyed by individAiah 
during convalescence y or after supposed complete recovery. 

Condition of infector, or interval 
Beport. of time after attack commenced in infector. 

ii. — Case 5 . . .27 days, 
ii. — Cases 6 and 7 . .26 days, 
ii. — Case 8 . . .21 days, 
▼ii. — Case 19 . . . Convalescent. 
X. — Case 22 . . .25 days. 

xi. — Case of governess . "A week or so" after discharge from hospital, 
xii.— .... Convalescent, but had offensive discharge from 

nose. 2 weeks after discharge from hospital, 
xiv. — Case of C. T. . . 3 or 4 weeks or more. Paralytic symptoms, 
xiv. — Case of Oct. 11th . About 4 weeks. Convalescent. 
XV. — Case of A. . . About 5 weeks. ** Well." 
XV. — Case of E. M. . . Convalescent, 
xvi. — Case of boy aged 6 . Convalescent, 
xvi. — Case 31 . . .3 weeks after attack, 
xvii.— Case of B. and others About a month, 
xvii. — Case of Albert . . More than a month, 
xix. — Case of G.'s daughter Convalescent from unrecognised diphtheria ; voice 

affected, glands of neck swollen, 
xxiv. — .... About 4 or 5 weeks ; convalescent, but had sore 

throat. 
xxvi. — Case of M. . .A month or more; convalescent, but had sore 

throat, 
xxvii. — • . • • Returned to school with debility, weakness of 

vision, and peculiar voice; 38 days after 
attack, 
xl. — Case 65 . • . 3 weeks; convalescent. 

xl. — Case 66 . • 2 or 3 weeks ; convalescent. Short interview in 

open air. 
xlii. — .... Paralytic symptoms only noticed, 
xlvi. — • • . .2^ months, 
liii. — .... Just recovered ; throat sore. 

Table VI. — Examples of infection apparently conveyed in 
incubative or very early stage of disease. 

Beport. Condition of infector and duration of exposure. 

v.^Case 11. The three days before infector was taken ill. 
V. — Case 12. The three or four days before infector was taken ill. 
xii. — Case 23. Short interview and kissing in open air ; day before diagnosis 

of diphtheria ; infector able to attend school, 
xii. — Case 24. For two days preceding diagnosis of diphtheria (sore throat 

during this period). 
XV. — Cases of J. W. and H. Infector attended same school up to time of 

sickening. 
XV. — Cases of three children infected by H.'s sister. This case is of very ques- 
tionable value, as the children had been at school with H. 
xvii. — Case of A. G. Five days before " white patches were seen," but a few 

days after suffering from ordinary cold, and on day of 
vomiting. 
xxi. — Child ceased attending school owing to severe sore throat. Three cases 

of diphtheria and four of sore throat four days later, 
xii. — Case of C. Attended same school up to developed attack. 



Diphtheria. 9 

Sore throat and unrecognised diphtheria. 

The reports quoted in the following pages afford many 
instances in which the infection of diphtheria was conveyed 
by persons who themselves were not known to have suffered 
from the disease. These instances appear to belong to two 
categories : in the one the person who conveys the infection 
has suffered from a sore throat not recognised as being 
diphtherial^ in some cases even after medical examination ; in 
the other the individual has not suffered from any throat 
affection, nor from any other obvious disease. This has been 
very clearly put by Dr. Airy in paragraphs 5 and 6 of his 
report, here numbered v. 

Without attempting to enter on a discussion of the patho- 
logical nature of these cases of obscure sore throat followed 
by diphtheria in the same family or school, it may be well to 
indicate the clinical varieties in connection with which this 
event has been observed. 

In the first place it seems probable that in many instances 
the sore throat is clinically a mild but recognisable form of 
diphtheria. Many instances might be quoted in proof of this. 
Dr. Blaxall, in his Report upon the Long -continued Prevalence 
of Diphtheria in the U. 8. D. of Taunton (September 6, 1883), 
speaks of the concurrent testimony among all classes as to the 
general and continued prevalence of sore throat throughout 
the town. *^ It was," he adds, " no uncommon thing to hear 
from infected families that prior to their own attack their 
friends or neighbours had suffered from sore throat ; and upon 
my making inquiry of these latter persons it appeared that 
their illness had been of so mild a character that no medical 
man was consulted. At the same time, from the particulars 
they gave me, I was satisfied in my own mind that in some 
instances the nature of the illness from which they had 
suffered was diphtheria.^' As an example he quotes the case 
of two children whose mother stated that she observed white 
patches in their throats, and that afterwards their voices were 
much affected, and their eyesight very bad, insomuch that 
*' the little girl could not see to thread her needle." 

Dr. Parsons, in a report on diphtheria at Roche and St. 
Stephen's, Cornwall, writes : " I learnt from more than one 
source that sore throats were very prevalent in Roche last 
autumn. Thus the schoolmaster at the Roche Board school 
states that at the time when diphtheria was prevalent, and to 
a less degree before and afterwards, many of the school 



10 Diphtheria. 

children had sore throats, and used to come to school with 
their necks tied up in flannel. Experience gained elsewhere 
has shown that outbreaks of diphtheria are frequently 
accompanied by a similar prevalence of sore throats not dis- 
tinctly diphtheritic in character, and has shown it to be 
probable that though such cases may not, from a clinical 
point of view, come within the definition of diphtheria, they 
are essentially of the same nature, and that a susceptible 
person coming in contact with one of them may contract the 
disease from it in a severe form/* Further on he states, " In 
September, 1887, diphtheria broke out in five households in 
Nanpean and Currian, the first case in each being a child 
attending the Board school at Nanpean, and most of them 
being in the same class. Four out of the five children were 
cousins, and used to meet elsewhere than at the Board school. 
The schoolmaster informs me that about that time a number 
of children at the school had sore throats ; indeed, two of his 
own children suffered, and one had to keep his bed for two 
days. The medical man who saw the schoolmaster^s children 
tells me that they suffered from ordinary inflamed sore throats, 
not diphtheria. I saw at Currian in one household a girl 
with decided diphtheria, and a sister suffering from quinsy, 
a single tonsil being much swollen and inflamed, but without 
any diphtheritic exudation. In another family at Currian I 
found three children all suffering from sore throat, but 
without any of the characteristic appearances of diphtheria." 
In this connection the observation made by Mr. Spear 
(Report xx) is of great interest ; seven children were infected 
on the same day by the same case of severe sore throat ; all 
seven were taken ill with fever and sore throat four days later, 
but in three only was the throat affection distinctly diphtherial. 
In another epidemic reported on by Mr. Spear (Spilsby, May, 
1885) a child died of diphtheria on June 7, 1883. The next 
case of unequivocal diphtheria was a child who sickened on 
November 13, but in the interval there had been in the 
neighbourhood numerous cases of sore throat. Mr. R. D. R. 
Sweeting, in a report on diphtheria in Herefordshire (1886), 
states that ^^ minor sore throat existed in families coincidently 
with true diphtheria, and in some cases a trivial throat affec- 
tion appeared to give rise by direct infection to severe and 
fatal diphtheria. Again, cases deriving infection from a 
common source showed some membrane, others none at all; 
the latter cases suggest the existence of an abortive form of 
diphtheria, analogous to that of smallpox without eruption.*' 



Diphtheria, 11 

The same inspector observes as to an epidemic at Tottenham, 
" ' sore throat ' often preceded and followed diphtheria in the 
same house and family, appearing to act as a link to undoubted 
cases of diphtheria/* In reference to an epidemic at Cheshunt 
(1S85), he states that the epidemic was mainly spread 
through the school. Duriug December, 1884, and January, 
1885, numerous cases of ^^ simple sore throat*' occurred among 
the school children. Such children returned to school in 
various stages of convalescence. The first recognised case of 
diphtheria occurred on February 7, and a series of cases fol- 
lowed among the school children. " It can hardly be doubted^ 
therefore, that in this instance, as in other similar ones that 
are recorded, a malady that was known only as a simple sore 
throat had the sudden ability, when * introduced into the 
school, of producing amongst the attendants at that school 
severe and fatal diphtheria.** 

The importance of this question in connection with the 
subject-matter of this report is further exemplified by the 
following remarks made by Mr. W. H. Power in writing in 
1883 {Report to the L. G. B, on Diphtheria in Pirbright, and 
on the Influence of the School there in the Behaviour of the 
Disease) : — ^^Not infrequently severe and fatal diphtheria 
appeared destitute or well-nigh destitute of power to infect 
other children living along with it while, on the other hand, 
cases of very trivial sore throat or ^ colds ; * that were not 
perhaps heard of (except by close questioning), often pre- 
ceded and were seemingly responsible for after occurrences 
of true and fatal diphtheria in the family. Especially was thia 
apparent capacity of mere sore throat for breeding malignant 
diphtheria noticeable in regard of families comprising many 
young children. In such families severe or fatal cases of 
diphtheria tended to occupy a position midway in a series of 
attacks that began as sore throat and ended in similar fashion. 
And further, we got a suspicion, though the instances were 
too few to justify any conclusion thereon, that, given the 
occurrence about the same time of two or more cases of trivial 
sore throat among children of a large family, such occurrence 
was likely to be quickly followed by severe diphtheria attack 
in one or more children of that family.** 

Numerous other instances of the endemic prevalence of 
^' sore throat ** with occasional cases of recognised diphtheria 
might be given, and a few will be found in the following pages » 
The circumstances which determine the clinical characters 
cannot be discussed here, but frequently, as in the epidemics 



12 Diphtheria. 

recorded in Eeports xxxiv, Ivi, Ivii, Ix, the gravity of the dis- 
ease would appear to depend upon the presence or absence 
of gross sanitary defects in the houses of the individuals 
exposed to infection. 

The clinical characters of the sore throat which may be 
observed in connection with epidemic diphtheria appear to 
vary a good deal ; Mr. Spear has written on this point at some 
length in the report from which an extract will be found 
below (see Eeport xliii). Follicular tonsillitis, suppurative 
tonsillitis, chronic tonsillitis with chronic enlargement of cer- 
vical glands, and quinsy are among the terms which have 
been used with more or less frequency. 

Diphtheria and scarlet fever. — In some epidemics true 
diphtheria has been associated with an epidemic of true 
scarlet fever; that is to say, the two diseases have been 
present in the same village at the same time, and the members 
of the same family have suffered some from one, some from 
the other, and some first from one (generally diphtheria) and 
then from the other. Under such circumstances it becomes 
practically impossible to disentangle the history of separate 
infection, and it often appears as if the one disease had been 
produced by the other. The reports here numbered liv, Iv, 
Ivi, Iviii, xlvii, and xvii, especially if read in the order indi- 
cated, will illustrate the difficulty, and at the same time afford 
evidence of the correctness of the view above expressed. It 
appears, further, that in some instances a membranous sore 
throat may complicate scarlet fever, and imitate very closely 
the clinical features of diphtheria. An example of such an 
occurrence is afforded by the epidemic which is the subject of 
the report by Dr. Parsons here numbered Ivii.* 

Fomites. 

There is good evidence that the infection can be conveyed 
in clothes and retained in them for considerable periods. 
Beport xvi contains an instance in which soiled linen appears 
to have preserved the infection in a most virulent state for 
a month or more; in Report xxxiii mention is made of an 
instance in which the infection was believed to have been 
preserved in clothes for four months; in another epidemic 
(Report xl) it appeared highly probable that a family, which 
had escaped at an earlier date, was infected by clothes which 

* This subject may be pursued in Dr. Thome Thome's recent work on 
Diphtheria : its Natural Historic and Prevention, London, 1891> p. 63, et eeq. 



Diphtheria. 13 

liad belonsred to children who had died of the disease about 
seven months earlier. Dr. Parsons (Eeport xlix) records an 
instance in which in two households outbreaks of diphtheria 
followed the use of a bed, given by a neighbour, upon which 
a patient suffering from diphtheria had slept. An interesting 
example of persistence of infection in a house is to be found 
in Eeport xvii, the retention of infection being apparently 
due to imperfect preparation of a bedroom for disinfection. 
A somewhat similar but longer history is related by Dr. 
Gresswell (Report xxv) ; in this case diphtheria appeared 
again and again among the servants of a farmhouse after 
spring or autumn " cleaning.'' 



Conveyance of infection by persons who did not suffer. 

Turning now to the examples of conveyance of the infec- 
tion by persons who have not themselves suffered from illness 
of any kind in the interval, it will be found that in the 
majority of the cases the person who thus conveyed the infection 
was at or about the time engaged in nursing patients in the 
acute stage, or was otherwise in intimate contact with such 
patients. The evidence, however, in many of the cases is 
far from being conclusive, and amounts only to strong pro- 
bability. Report xii contains an example : three children were 
removed from an affected house, and had no contact with the 
rest of the family for nine days ; then the grandmother, who 
had not had sore throat nor any symptoms of diphtheria, 
but had nursed two of the cases ill in her house, called and 
saw the three isolated children ; she kissed one of them, and 
this child was attacked by diphtheria two days later (Case 25). 
In Report xvi an instance is noted in which it was thought 
probable that an elderly woman, who had on several occasions 
gone to an infected house to nurse children suffering from the 
disease, was the means of conveying the infection to her 
daughter, although she did not herself suffer from the disease. 
A more convincing case is related in the second paragraph of 
the abstract of one of Dr. Blaxall's reports (xix) : a mother 
who did not suffer from diphtheria, but who was nursing one 
of her own children suffering from an early stage of the 
disease, visited a friend who lived five miles away, and took 
an infant in her arms for a short time; this infant was 
attacked two or three days later; no other source of infection 
could be traced. Report xxxi contains two instances in which 



14 Diphtherid. 

it seemed probable that the infection was conveyed by persons 
who were in more or less intimate contact with patients ; in the 
one case the conveyer of the infection actually slept with a 
patient, but in the other the symptoms in the person from 
whom the infection was supposed to be derived did not appear 
nntil two days later. Not much value, therefore, can be 
attached to this instance. The evidence is rather stronger in 
the instance contained in Report xl : two children from an 
infected house returned to school ; they had not suffered from 
the disease, but a boy at the school to whom they gave an 
apple was attacked six days after these two children had 
returned to school. In another instance it was thought pro- 
bable that the infection of a woman who sold milk was 
brought about by her having had frequent dealings with the 
parents of a child who was suffering from fatal diphtheria. 
Another example of infection conveyed by a person who had 
resided in an infected house without, so far as appears, coming 
into very intimate contact with the sufferers is afforded by a 
youth (Report x) who came from an infected house to sleep 
every night in another house. This youth did not suffer, but 
the first person attacked in the house to which he went to 
sleep was the master, who was the only person to come in 
contact with the lad. Dr. Airy (Report v) mentions the case 
of a young servant, employed in a house in which a woman 
was suffering from diphtheria in an early stage, who appeared to 
have been the means of starting an epidemic in two isolated 
cottages, though not attacked herself. Report xii contains 
a case in which a woman residing in a village visited an 
infected house in a neighbouring town ; though she was not 
herself infected, the first case in the village was her child. 
The facts connected with another case (Report xxxvii) seemed 
to make it probable that infection was conveyed to a house 
by a lady who visited certain infected cottages, but did not 
herself suffer from the disease until a much later date, and 
after she had passed through a period of great anxiety, during 
which she was engaged in nursing members of her family. 
The same report mentions an instance in which it was thought 
that a woman who had helped to ^^ lay out " a child dead of 
diphtheria conveyed the infection to her own children, 
although she did not suffer herself. 

As to the mode of infection in such cases as those above 
enumerated, it is, of course, highly probable that in the 
majority the infection has been conveyed in clothes, but in 
some instances the interval has been long enough to warrant 



Diphtheria. 15 

the suggestion that the person who conveyed the infection may 
have suffered from diphtheria of so mild a type that it did not 
cause the sufEerer to consider himself or herself ill. 



Infection by personal intercourse. 

In the great majority of the cases reported to the committee 
infection was to be traced to personal contact, direct or 
indirect, and the history of nearly all village and school epi- 
demics points strongly in the same direction. Upon this head 
it will not be out of place to quote some observations made by 
Dr. Parsons on the influence of the parish boundaries on the 
mode of spread of diphtheria. 

'^ It is to be observed," he writes, " that a parish is an area 
marked out in most cases by purely artificial or arbitrarily 
selected boundaries, and not conforming to any natural limits 
of physical or geological configuration; but, on the other 
hand, that the inhabitants of a rural parish have commonly 
more opportunities of intercommunication with each other — 
e. g. at the parish schools, at places of worship, at .work, at the 
village shop, the public-house, &c. — than they have with the 
inhabitants of even closely adjoining parishes. In other 
words, a parish is commonly a social, not a physical division. 
If, then, we find a disease limited in its prevalence to the 
inhabitants of a particular rural parish, where there is no com- 
munity of sewerage, or water or milk supply, the inference is 
that it is propagated by personal intercommunication rather 
than by natural physical agencies ; and my inquiries have led 
me to the conclusion that this is the way in which diphtheria 
has been propagated in Bversholt. The village of Bversholt, 
if such it can be called, consists of no fewer than fourteen 
more or less distinct hamlets or Ends ; some of these consist 
of but two or three houses, and at only two of them. Church 
End and Lower Ba.d's End, is there anything approaching a 
olose aggregation of houses on the ground. The cottages are 
of a good class. . . . The limitation of the disease to the 
parish of Eversholt enables us to exclude atmospheric or tel- 
luric conditions, for on each side of Eversholt are other villages, 
little more distant from it than some parts of Eversholt are from 
one another, standing on the same soil (except Milton Bryant 
to the south, which is on the gault clay), and having doubtless 
the same or very nearly the same climate ; yet these other 
villages have escaped the disease so far as is known, certainly 



16 Diphtheria. 

from any extensive or fatal prevalence. I have met with other 
instances of a limitation of the disease to a single parish^ 
adjoining parishes similar in their physical circumstances 
having escaped^ at the time at least/' 

Other sources of infection. 

While the agency of personal intercourse as the main agent 
in the spread of an epidemic can hardly be disputed, it 
must be admitted that in a very considerable proportion of 
epidemics it is impossible to trace its operation in the earliest 
case. Dr. Airy has observed {Report to the L, G. JB. on 
Several Outbreaks of Diphtheria in the Fourth Quarter of 1879) 
that diphtheria '^ will break out at a lonely farmhouse in a bleak 
waste, where intercourse is rare at all times, and, as regards 
infection, utterly untraceable. In the subsequent extension of 
diphtheria the agency of personal intercourse can generally be 
traced. This brings out more strongly the independent 
character of the commencement of the outbreak." 

The inquiry made by the committee was not specially 
directed to this point, but attention may be called to the cases 
collected by it in which modes of infection other than personal 
intercourse appear to have been operative. 

Cesspits and foul drains, — In a few cases infection is attri- 
buted to the emanations from the emptying of cesspits or 
foul drains. Examples are Cases 1, 2, 36, and 75, and the 
occurrence described in Report Ix. The period of incubation 
in these cases varied considerably. In Case 75 (Report li) it 
was only a few hours. In Case 2 it was less than forty-eight 
hours. In Case 1 it was less than four days. In Case 36 
(Report xvii) it was not more than eight nor less than five 
days. 

Accepting the theory that the emanations were the causes 
of the subsequent diphtheria in these cases, two explanations of 
the source of the specific infection are tenable : it may have 
originated denovo, or the infective material may have entered 
the drain or cesspit at some long antecedent date, and have 
been preserved in the foul material therein contained. An 
instance in which this last event is believed to have occurred 
will be found in Report Ix. 

Domestic animals, — In a few instances infection is believed 
to have been conveyed by domestic animals. The cases do 
not afford any precise data as to the period of incubation, or 
of the duration of infection. In one instance (lix) the interval 



Diphtheria. 17 

between a visit to a farm at which the fowls were sufiEering 
from a disease thought to be diphtherial and the first case 
was said to have been about a week ; in no instance is there 
any evidence pointing to an unusually short period of incu- 
bation. 

Milk, — In three instances only among those reported to 
the committee was milk the medium of distributing the in- 
fection (Reports xiii, xxxix, xliv). In one only (xiii) do the 
facts give any information as to the length of the period of 
incubation^ and in this instance no more can be said than that 
the circumstances are compatible with an incubation period 
of seven days or less, and are probably incompatible with a 
much longer period. An abstract of Mr. Power^s report on 
the epidemic at York Town and Camberley is given mainly 
because it throws light on the persistence of the infective 
condition in milk, and even indicates that milk becomes more 
virulent when kept for twelve hours or more (Report xxxix). 
Dr. Bruce Lowe's observations (Report xliv) are of interest 
in this place, as they afEord a striking contrast to the general 
behaviour of diphtheria : he remarks the " complete indifiEer- 
ence to locality " in an epidemic traced to milk, which, he 
adds, is in " accord with previous experience of milk diph- 
theria ;*' whereas, as has been pointed out above, epidemics 
of diphtheria are, under other conditions, very largely limited 
or extended by circumstances of locality. 



Conclusions. 

Incubation period. — The incubation period of diphtheria 
does not as a rule exceed four days, and is more often two 
days than any other period. Not infrequently it extends to 
five, six, or seven days, but it is doubtful whether it ever 
exceeds the last-named period. 

Infective period. — A person may be infected by a patient 
suffering from diphtheria (a) in the incubative stage; (b) 
during the developed attack; (c) for a period of long but 
uncertain and probably varying duration after apparent 
recovery. In such cases of late infection some uiJiealthy 
condition of throat will, as a rule at least, be found to have 
persisted, or possibly to have recurred. 

Persistence of infection, — The infection of diphtheria can 
be retained in clothes, carpets, and other fomites for months, 
perhaps years. 

B 



18 Diphtheria. 

Vnrecognised diphtheria. — The infection of diphtberia may 
be derived from cases so mild that the patient never comes 
under medical treatment^ or presents symptoms so little 
characteristic that their true nature is not recognised even 
after medical examination. 



Diphtheria. 19 



CASES. 

Cases 1 and 2. 

Communicated by Dr. Jambs Wbatss, Longton, Staffordshire. 

IrrfecHon probably from foul drain. — A. 0. {Gate 1), about 12.30 p.m. 
on Good Friday, cleaned out an offensive drain in the yard of his house. 
It carried slop water, and had become stopped up. He also at the 
same time emptied an offensive rain-water barrel. His daughter, 
B. 0. {Case 2), aged 10, stood beside him, watching his operations. 
B. 0. was restless and feverish on the night between Saturday and 
Sunday, and early on Sunday morning complained of sore throat. 
Dr. W. saw her about 10 a.m. on Sunday. She was then ill and 
anxious ; there was a small piece of membrane on one tonsil, and the 
whole throat was dark. On the next day she was better ; the mem- 
brane had not extended, and from that date she made a good recovery. 
A. C. had well-marked symptoms of diphtheria on Tuesday morning. 
He made a good recovery. 

Case 3. 

Communicated by Dr. R. BBt7CB Low, Helmsley. 

Very long interval. — Two brothers, E. and Y., left Dublin, where 
diphtheria was prevalent at the time, and arrived at a monastic school 
kept by Benedictines on August 27, 1875. There were 100 pupils and 
between 20 and 30 priests ; the monastery is in a remote neighbour- 
hood ; no cases of diphtheria or enteric fever had ever been known to 
occur in it ; the hygienic arrangements were " of the best descripticm ;^* 
discipline was very perfect ; there was very little, if any, contact with 
the outer world; there was no diphthena in the district round the 
monastery, and T. (Case 3) was not near any village or town during 
the time which elapsed between his arrival at the monastery and his 
attack. Special inquiry was made as to the receipt of any parcel, and 
it was ascertained that no parcel or packet was sent from Duolin to thia 
or anv other boy between August 27 and October 12, 1875. There may 
have Deen letters. Y., who was aged 12, was attacked by diphtheria on 
September 29, 1875 (thirty- three days after arriving at the monastery),, 
and died on October 12. His elder brother, E., had no symptoms of 
illness either before or after these dates. Y. was isolated as soon aa 
the disease was recognised, and no other cases occurred in the school. 

Case 4. 
CoBii&unioated by Dr. Altbbd Clabeb, Bri^de Surgeon. 

A man (Case 4) who had been isolated at another house went home 
on September 26 to his ehild, who died September 27. He remained at 
home and sickened, October 8, with diphtheria. 

Four cases of diphtheria occurred in the family of Corporal F., one- 
on November 5, 1888, followed by three others on November 6 and 8. 
One death occurred on November 16. The others convalesced, and 
the house was whitewashed and disinfected on November 18. On 
December 11 the baby, eleven months old, was attacked, and died 
December 15. It is not stated that the baby was kept apart from 
the convalescent children — probably not. 



20 Diphtheria. 

Communicated by Sir Geobob Buchanan, F.B.S., late Medical Officer 

to the Local Goyemment Board. 

• 

1. 

MJr. W. H. Powbb's Report to the Local Government Board on Prevalence of 
Diphtheria and other Throat Illness at Badwinter^ dated August 8« 1877. 

'* No doubt that to a very large extent diphtheria and its allied 
throat complaints have spread in Badwinter by infection from person 
to person. . . . Between the occurrence of the first case in each 
house and succeeding ones an interval, an ' incubation period,' of two 
to four days was commonly apparent." 

ii. Cases 5 to 8. 

Dr. Blazall's Report to the Local Government Board on the Sanitary 
Ck)ndition of Padstow, &c.^ p. 7, dated March 13, 1878. 

Infection conveyed by a convalescent — H. B. left the Board school on 
December 12, suffering from diphtheria. He returned to school on 
January 8. On January 15 another child (Cose 5) at the school was 
attacked, and died January 24. 

Infection conveyed by a convalescent, — Two children, attacked on or 
about February 7, returned to school March 5. Between March 9 and 
12 four fresh cases occurred amongst the school children. Two of these 
fresh cases (Causes 6 and 7) resided in villages where there had been 
no previous cases of diphtheria. The incubation period in the four 
cases was not more than four days in the shortest and seven in the 
longest. 

Infection conveyed by a convalescent. — E. W. left the Board school 
on June II, suffering &om diphtheria, and returned to school on July 2. 
On July 6 another child {Case 8) in the school was attacked. Incuba- 
tion period not more than four days. 

iii. Case 9. 

Dr. Blaxall's Report to the L. G. B. on an Epidemic of Diphtheria in the 
R. S. D. of Scnlcoates, Torks, dated January 5, 1878. 

Infection during incubation, and hie convalescence. — On May 3 a 
•child came home &om (day) school suffering from early symptoms of 
an attack of diphtheria, which was not recognised as such; first 
•case in this family. She was kept at home. On May 14 her sister, 
S. S. (Case 9), who was a domestic servant at Welton Wold, five miles 
a.way, returned home, remained there May 15, and went back to Welton 
Wold May 16. On May 18 she complained of sore throat, and on 
May 19 was seen by a medical man, who diagnosed diphtheria ; she 
was sent home on May 20. Shortly afterwards her mistress and 
an infant were attacked by diphtheria, and died. S. S. was the first 
case at Welton Wold. Incubation in S. S. not more than four days 
nor less than two. 

Speaking of the epidemic in general terms, Dr. Ballard says, '' It is 
noteworthy that the infection would appear to have been disseminated, 
hy sufferers when in the incubative and acute stages of the disease, 
and also after a long period of convalescence." 



Diphtheria. 21 

iy. Ccue 10. 

Dr. W. OaiB's Report to the L. G. B. on Diphtheria in the B. S. D. of 

Barnstaple, dated Jane 12, 1879. 

A girl, aged 3, attended, down to October 28 inclusive, a school at 
which a number of children had recently contracted diphtheria. Her 
mother was *' most positive that the illness " — diphtheria, from which 
she died on November 15—" dated from Novemoer 8 " — eleven days 
after last attendance at school. Between October 28 and November 8 
the child had been carefully kept from all intercourse with cottages 
already infected. 

V. Cases 11 to 13. 

Dr. Aiby's Report to the L. G. B. on Several Outbreaks of Diphtheria in 
the Fourth Quarter of 1879, dated December 11, 1880. 

Infection from patient in stage of incubation. — A private school, with 
nine scholars, in a village, reopened after harvest holidays on Septem- 
ber 8. One child, J. S., who had been staying at Forest Gate, near 
London, did not return till next day, September 9. On September 12 
J. S. was ill, and did not go to school. On September 15 she was 
seen by a medical man, who found her to have diphtheria. On Sep- 
tember 13 another girl at thifl school, M. W. (Case 11), was taken ill. 
She was seen by a medical man on September 15, who found her suffer- 
ing from diphtheria. A third case in the school, H. T. (Case 12), 
occurred on September 18. The only other child in the school who 
contracted the disease was a sister of H. T., who may have caught, 
and " in all probability " did catch the disease in her own home. J. S., 
M. W., and H. T. were the three occupants of one side of the same 
table at school. It will be noted that M. W. developed the disease 
one day after J. S., but that she had sat close to her at school on 
Septemper 9, 10, and 11; and if, as Dr. Airy concludes to be most 
probable, M. W. caught diphtheria from J. S., it must have been 
while the latter was in the incubative stage. M. W. had, during the 
holidays, been staying at a village about a mile from another village in 
which cases of diphtheria had occurred fifteen to eighteen months 
earlier, but there was " no evidence that she had been in contact with 
any person or thing that could be suspected of harbouring the infec- 
tion of diphtheria." Four cases in the family of H. T. were the only 
other cases in the village of Felstead. (In M. W. the period of incu- 
bation could not have exceeded four days; H. T. sickened five days 
after the last day on which M. W. was at school.) 

Fatal ** sore throat" — A servant girl in a carpenter's home in a 
small village had a sore throat on November 24, and returned to her 
own home, a quarryman's cottage in a distant village, on November 25. 
Diphtheria had first appeared in the carpenter's family on November 17. 
The servant remained at home until December 1. Her brother (Case 
13), aged 10^, was taken ill on December 4 (nine days after his sister 
had come home and three days after she left), and died on December 
11 of ulcerated sore throat. No other cases. 

Cttstomarymodes of spread ; unrecognised cases; (?)fomites. — Dr. Airy 
observed that, as a rule, if diphtheria was introduced into a family it 
was found that all or most of the children were attacked, some 
perhaps simultaneously, or at intervals of one or two days or a week, 
the parents at the same time often suffering from more or less severe 



22 Diphtheria, 

Bore throat. As to spreading by personal commnnication : (1) The 
most frequently operative circumstajice was residence under the same 
roof. (2) ^e next most frequently operative was sitting together in 
the same school. (3) Probably often disseminated at church and 
chapel. (4) May be caught by occasional visits to the bedroom, dwell- 
ing, or shop of a diphtheria patient. (5) A person who, having been 
exposed to diphtheria, suffers from sore throat not recogpiised as diph- 
theria, may yet start an epidemic in another and distant locality. (6) 
Diphtheria may he conveyed to a new locality by a person who has been 
in contact with a diphtheria paMent, but has not himself contracted the 
disease. Of this Dr. Airy gives the following example : — A girl, W., 
aged 13, in service at a house infected with diphtheria (woman in early 
stoge) went to her home, one of an isolated pair of cottages, high 
among mountains six miles away, on November 11. She remained at 
home until November 15. She heraelf had no sore throat, at least 
she was not ill, but shortly after her return to service two of her sisters 
who resided at home were taken ill with sore throat. They recovered, 
but early in December the infection appeared in the family residing in 
the adjoining cottage, and caused one death. Dr. Aii*y suggests that 
infection may have been conveyed in the clothes of the girl W., or 
about her person. 

vi. Cases 14 to 18. 

Mr. W. H. Powbb'b Report to the L. G. B. on Diphtheria at the Hospital for 
Sick Children, Great Ormond Street, dated November 15, 1880. 

The following cases are mentioned by Mr. Power as showing the 
periods intervening between the presumed opportunity for contracting 
diphtheria and actual manifestation of the disease in particular cases. 

K. (Case 14), aged 5^, admitted for rheumatism six days before 
being attacked with diphtheria. Not more than six days. Wa. (Case 15), 
aged 2^, admitted for pneumonia thirteen days before being attacked 
by diphtheria. Not more than thirteen days. Wi. {Case 16), aged 4A, 
admitted for typhoid fever fourteen days before being attacked by 
diphtheria. Not more than fourteen days. G. {Case 17), aged 3^, was 
under treatment for eighteen days for wryneck during the prevalence 
of the epidemic, and was discharged on March 14. This child was 
attacked on March 23, was readmitted, and died in hospital. Not less 
than nine days. B. {Case 18), aged 3A, was in the hospital for thirteen 
days before March 13, on which day he was discharged. Was attacked 
"not less than fourteen days" after leaving hospital, and died at 
home (exact dates not given). The disease was probably contracted in 
aU these cases from some common cause operating within the hospital, 
and affecting all patients. 

vii. Case 19. 

Dr. Pabboitb' Beport to the L. G. B. on Diphtheria at Gedney Grove End, Ac., 

dated December 26, 1882. 

L. (Case 19), a governess at an outlying farmhouse, was taken ill 
on October 17 with sore throat, which turned out to be diphtheria. 
She was at church on October 15, and sat "just on the other side of 
the aisle " to a Mrs. H., whose son had died of diphtheria on October 7. 
In the next cottage to Mrs. H., and under the same roof, lived a boy 
who began with £phtheria on October 9. Mrs. H. had probably con- 
veyed the infection in the first place to her son, as she had had sore 



Diphtheria, 23 

throat before the boy, and bad preyiously to that visited another cottage 
in which an earlier case of diphtheria had occurred. Mrs. H. was not 
•attended by a medical man. If the hypothesis is accepted, then infec- 
tion was conveyed by a convalescent from an unrecognised attack, and 
the incubation period was two days. 

viii. Ca«e20, 

Dr. Aibt's Bepwt to the L. G. B. on an Outbreak of Diphtheria at King's Lynn« 

dated July 24, 1882. 

During an endemic prevalence of diphtheria in King's Lynn a 
servant girl {Case 20), in a house next door to one in which a case of 
diphtheria occurred on October 10, was on October 17 sent to the village 
of Gayton, seven miles from Lynn. She sickened with diphtheria on 
October 22 (five days after cessation of exposure). Only one other case 
of ** sore throat " occurred at Gayton, the patient being a lad who had 
been lodging at Lynn and returned to Gayton ill on October 7. 

ix. Ccise 21. 

Dr. Pabsoks' Report to the L. G. 6. on an Outbreak of Diphtheria in the 

Sutton-in-Ashfield U. S. D., dated June 26, 1882. 

A girl (Case 21) living in service in another part of Sutton came 
home one Sunday afternoon to visit her friends. She saw and kissed a 
little girl living next door who was ill with an '* ulcerated sore throat/' 
which was pronounced by the doctor next day to be diphtheria, and 
proved fatal. The servant girl returned to her place, and on the Thurs- 
day {fou/r days after kissing the little girl) she was taken ill with diph- 
theria, which was followed by pharyngeal paralysis. 

X. Case 22. 

Dr. H. F. Pabsons' Beport to the L. G. B. on the Prevalence of Diphtheria 
during 1881-2 at Tempsf ord (unpuhlished), dated December 80, 1882. 

Conveyance of infection by a person not herself aUacked, — Infection 
was apparently brought to the village by a woman who had visited a 
house where diphtheria existed in Bedford. The woman herself 
-escaped, but her child whom she had not taken with her was the first 
to suifer. 

Infection by convalescent patient. — ^Two children, members of one 
family, attendmg school, were taken ill on November 2 and 16 respec- 
tively, and were removed to hospital November 16 and 18. After their 
•discharge from hospital they went back to school on December 11. 
On December 13 a girl {Case 22) who acted as monitor of the class 
which these two children had rejoined was taken ill with diphtheria. 

xi. 

Dr. Bl^xall's Beport to the L. G. B. on Epidemics of Diphtheria in the 

Taunton R, S. D., dated September 6, 1883. 

Infection by a convalescent patient. — In the family of Mr. B., residing 
at a water-mill, four sons were attacked with diphtheria in September 
1881 ; at this time the disease was probably imported by two of the 
sons who were first attacked and went to a school in the neighbourhood 
of which diphtheria then existed. The next case occurred in September, 
1882, the patient being the governess, who was in the habit of visiting 



24 Diphtheria. 

Tannton, wbicli was then infected ; she was removed to the hospital at 
Taunton, and subsequently went to Minehead where the B.'s also were 
staying, but in different lodgings. " At the end of a week or so she 
returned with the family " to the mill house, " and shortly afterwards " 
cases of diphtheria occurred in the house. 

xii. Cases 23 to 25. 

Dr. Blaxall'b Report upon the long-continued Prevalence of Diphtheria in the 
U. S. D. of Taunton, dated September 6, 1888. 

The inquiry was directed in consequence of a considerable epidemic 
which occurred in 1881-2. 

Single short interview with patient in incubaiive sta>ge. — P. (Ca^e 23), 
a child, was taken by her mother to a Kindergarten school, and while 
waiting outside was kissed by X., one of the pupils, who ran out of the 
school. It does not appear that P. entered the school. On the 
following day a medical man was called to X., and found her suffering 
from di^theria. Two days later (three to four days after the interview 
between P. and X.) the same medical man was called to P., and found 
her also suffering from diphtheria. 

A girl, B., in service in a family several members of which were 
suffering from sore throat of an indefinite character, was sent back to 
the Servants' Home suffering from sore throat. Two days after B.'s 
return to the Home she manifested symptoms of diphtheria^ and was 
sent to the hospital. Two days later 0. (Case 24), another inmate of 
the Home, who had been in contact with B., also manifested diphtheria. 
There had been no cases of diphtheria in the Home before B. The 
incubation period in 0. may have been four, but cannot have been less 
than two days. 

Infection apparently conveyed by a person who did not suffer, — A little 

firl in the family of Mr. H. was taken ill with diphtheria on November 
7, and died November 22. The four other children were sent away 
to their grandmother's in another part of the town on November 21. 
A second daughter, B., was here attacked on November 22. The 
remaining three children were kept apart from £., but remained 
in the grandmother's house until November 25, on which date the 
mother also sickened. On this day (November 25) these three children 
were removed to a house a few doors off; nine days later the grand- 
mother who had been nursing Mrs. H. and E. called at this house to 
see the children who had remained healthy. The grandmother, who 
entirely escaped the disease, and had no sore throat, kissed one of the 
children, a girl, L. {Case 25), aged 8, but not the others. Two days 
afterwards L. was attacked. 

Infection by a convalescent patient, — One of a family of six children 
was attacked with diphtheria and sent to hospital ; on being discharged 
from there he was taken to Minehead for a week or two, and then re- 
turned to his own home. His voice and vision were much affected, 
and there was a free and offensive discharge from his nose. Shortly 
afterwards a second child and a servant were attacked. 

Conveyance of infection by a person not himself attached, — A youth 
went to the house of Mr. Hy. every night to sleep. " The youth was 
not himself attacked, but he came direct from a house in which four 
or five cases of diphtheria were present." Mr. Hy. was the only person 
who came in contact with this lad, and he contracted the disease, the 
infection subsequently spreading to his two sons and the servant. 



Diphtheria, 



25 



ZUl. 

Mr. W. H. Powbb's Report to the L. G. B. on an Outhreak of Diphtheria in the 

Hendon U. S. D., dated April 5, 1883. 

Milk. — There was a special incidence of diphtheria and throat illness 
among the customers of a particular dairy, and especially on large con- 
sumers of the milk in an uncooked state. The evidence to connect this 
milk with the diphtheria, though it fell short of absolute demonstration, 
was very strong. There was abundant evidence that shortly before the 
outbreak " the milk distributed from this particular dairy was ropy or 
stringy. Especially was this the case on the Ist and 2nd of January." 
The following cases constituted the beginning of the outbreak : 



Household. 


Age. 


Date of attack and nature of illness. 


Interval after Jan. 1. 


C.L. 

S. G. 
T. P. A. 


Nurse 

8 

3i 

1* 

Cook 

Servant 


Jan. 2. — Diphtheria 
»» » 

ii »» 
»» ft 


1 day. 
4 days 

99 
M 
99 
99 


T. P. B. 
H. H. A. 


13 
10 
11 
9 
13 
3 children 


>» 99 

Jan. 6. „ 

Jan. 5. — Diphtheritic sore throat 
„ 5 and 6. — Sore throats 


99 

5 days. 
4 days. 
4, 4 or 5, and 5. 


T. P. C. 

it 
H. M. B. 


6 

3 

4 adults 


„ 5. — Diphtheria 

„ 5 and 6. — Sore throats. 


4 days. 

5 „ 

4, 4 or 5, 4 or 5, & 


T. P. D. 


8 


i, 5. — Diphtheritic sore throat 


4 days. 


»» 


6 


» » 


» 


T. P. E. 


4 
3 
2 children 


» 9* 

Jan. 8. — Fatal diphtheria 
Jan. 5 and 6. — Diphtheritic 
sore throat 


7 „ 
4 and 5. 



XIV. 



Dr. DowKEs' Report to the L. G. B. on an Outbreak of Diphtheria at Oaksey, in 

the Malmesbury R. S. D., dated June 15, 1883. 

Infection by convalescent paiient with paralytic symptoms; suggested 
increase in infectivity at a late stage — A child, 0. T., aged 10, then 
residing with her mother at Cirencester, ceased attendance at school on 
May 2 on account of sore throat of a nuld character not recognised as 
diphtheria, and on May 22 was sent to her grandmother at the village 
of Oaksey to recruit. " On her arrival, or soon after, it was noticed by 
several persons that her voice was peculiar, 'just like some of the 
children who had diphtheria.' Moreover her sight was defective, and 
siie had difficulty in swallowing, so that * bits of food stopped in her 
throat.' On June 10, nineteen days after C.'s arrival, there sick- 
ened with diphtheria E. S., aged 3, living with the same grandparents, 
and W. S., aged 5, living at their sons, next door. Neither had attended 



26 Diphtheria. 

any school, nor had been exposed to any known source of infection 
other than 0. T." Dr. Downes does not think that the evidence ^'jusH^ 
Jiea cm hypoiheais of nineteen days* incubation. It indicates rather that 
the quality of infectiousness did not attach itself to her throat illness 
until some time after her arrival at Oaksey, or that till then its inten- 
sity, or at least its potentiality of diffusion, was small." He advanced 
the suggestion " that in diphtheria there may be a period in the later 
stages or in convalescence when the contagiv/ai becomes more readily 
transferable. For example, there is reason to connect the November 
explosion with " a patient " who was attacked October 11 and returned 
to school on October 30. But no case followed until November 14, 
although no other source of contagion could, by the strictest inquiry, 
be discovered. And it is still more curious that the main part of this 
•explosion yet later in the month was in its incidence remarkably asso- 
ciated with the movements of this child. That an explosion of diph- 
theria should centre round a single case is quite in accord with my 
experience elsewhere." The case which occurred on November 14 was 
a child who was a great friend of the child attacked on October 14, and 
attended the same school. 

XV. Cases 26 to 29, 

Dr. Blaxall's Report to the L. G. B. upon the Sanitary Condition of Calne in 
connection with an Outbreak of Diphtheria and Typhoid Fever in that town, 
dated June 17, 1884. 

Infection by a convalescent paiient — The epidemic (May to December, 
1883) was due to introduction from without, and disseminated by the 
promiscuous intermixing of infected and healthy, some of the schools 
playing a prominent part in the dissemination. A boy. A., aged 11, who 
resided in a village about a mile from Oalne, was attacked with severe 
sore throat on May 4. He probably contracted the disease from a 
family of infected relations living in another village. A. had attended 
T. school in Oalne up to the date of his illness. He was absent from 
school five weeks, and during this period no further case occurred in 
the school. A. again began to attend school on June 5. On June 11 
(six days after A.'s return) a girl, W. R. {Case 26), in the same class with 
A., was attacked. Other cases followed. 

** Simple sore throat " followed by cases of diphtheria, — ^Meanwhile 
the disease had been introduced into the town by another person, a 
servant girl, B., who returned to Oalne, after an absence of about three 
weeks, on or about May 11. IShe had been away with her mistress's 
children, one of whom had suffered from what was regarded by the 
medical practitioner called in as a sore throat of a very slight character. 
B. first saw a medical man on May 14, and her illness was recognised 
as diphtheria on May 15. On that day she was sent home. W ., a 
baker's man, apparently contracted the disease from her, and W.'s 
children from him. One of these children, John W., attended the B. J. 
school up to June 6, when he went home ill (he died June 14). The 
next case in the school was H. (Case 27), who went home ill on June 9 
(three days after John W ). No fresh case occurred in the school 
until June 18, when H.'s sister and three other pupils sickened: H. 
returned to school on June 18. If the three other children were 
infected by H.'s sister, this must have been either derived from her 
while in the incubative stage or carried in her clothes. 

E. M., who had diphtheria during the holidays, began to attend the 



Diphtheria. 27 

<7. Bcliool at its reopening on August 27 ; she was then in the conva- 
lescent stage. Two other children, friends of hers, attending the same 
school, sickened on September 4 and September 10 respectively, eight 
•days after reopening of school in the nrst case (Case 28), and in the 
second case six days after the first case. 

During the girl B.'s illness her brother (Case 29) came down from 
London for the day, and three or four days after his return to town he 
ivas attacked with diphtheria. 

xvi. Cases 30 and 31. 

Dr. Pabsonb' Report to the L. G. B. on Outbreaks of Diphtheria at Hambledon 
aud other places in the Droxford R. S. D., March 24, 1884. 

Hambledon is a large but isolated village on the Hampshire Chalk 
Downs. Diphtheria was probably imported from Portsmouth, the nearest 
town. The earliest cases were obscurely referred to antecedent cases 
of scarlatina, and were not recognised as diphtheria. In the two 
following cases the duration of incubation could be fixed. 

Case 30. — Mrs. went in early one Saturday morning to see a 

neighboar's child who was dying of diphtheria; this was the only 
occasion. She was much frightened. On Monday afternoon she was 
taken ill herself with diphtheria. In this case the incubation period was 
fifty-seven hours. 

A boy of six who died of diphtheria had played in a cart-shed with 
another boy convalescent from the disease, who had given him a bite 
of an apple. 

Case 31. — A boy of five, residing in an outlying part of the parish 
where there were no other cases, met one Monday in the harvest-field 
an older boy just recovered from a slight attack of diphtheria three 
weeks previously, who gave him a ride "on pickaback." On the 
following Saturday the little boy was taken ill of diphtheria, the incu- 
bation period being thus in this case five days. 

Infection conveyed by person who did not suffer, and by clothes. — 
At the neighbouring village of Shedfield a severe circumscribed outbreak 
was originated in 1882 by a carpenter's apprentice who spent a few 
days at Portsmouth, and on his return to work was laid up for ten 
days with sore throat, followed by difficulty of swallowing which lasted 
some time. The carpenter's children suffered severely (five deaths in 
six cases). The father also had it, with subsequent paralysis of arms. 
Mrs. F. (senior), an elderly woman who lived in a neighbouring house, 
went to the carpenter's a few times to nurse the children. About a 
fortnight afterwards her daughter, aged 13, who is said not to have been 
to the carpenter's herself, was taken ill of diphtheria, and died on 
June 21, after three weeks' illness, her mother (who had had diphtheria 
twenty-five years before) not being affected. After the girl's death the 
house was thoroughly fumigated, the paper stripped off', and the walls 
lime- washed ; and, as it was thought, all infected clothing was washed 
or fumigated. It was hoped that the disease was at an end, but five 
weeks later it broke out in the household of Mrs. F.'s son, living in a 
neighbouring cottage. For a long time this recurrence of the disease 
was difficult to account for, but it was ascertained that some of the 
clothing infected by Mrs. F.'s daughter was put away unwashed, and 
that another daughter, who came home a month later to live at her 
brother's, turned it out and washed it ; she caught diphtheria and died. 



28 Diphtheria, 

In the house of Mr. F. junior there were four cases of diphthjeria, of 
which three died on the same day. 

xvii. Cases 32 to 36. 

Dr. Pabsoks' Report to the L. Q. B. on the recent Prevalence of Diphtheria at 
Eversholt, in the Woburn B. S. D., May 12, 1884. 

Infection by convalescent unrecognised case, — A gii*l, aged 11, was away 
from school on account of illness from the end of June to the end of 
July. She was considered by the medical officer of health to have had 
diphtheria affecting the nasal passages, from the after effects of which 
she had not completely recovered when she was seen by him on 
August 24. On July 23 a school treat was held, at which this girl B. 
was present. The day was wet, and the children, about 100 in number, 
took refuge in a cow-shed. Among those at this treat were two children 
of the village shopkeeper at Church End, one of whom (Case 32) was 
taken ill on or about July 25, the other on or about July 31 ; both cases 
were fatal. These were the first recognised cases of diphtheria, but 
other cases of the same nature occurred about the same time amoDg 
other children who had attended the treat, and Dr. Parsons considers 
it ** likely " that the infection yvas acquired there. 

Scarlet fever and diphtheria in members of same family, — It is pro- 
bable that the infection was introduced into Eversholt by a boy, Albert, 
who lived at Roehampton, Surrey. Three other children of Albert's 
family had suffered at Boehampton from diphtheria in April and May, 
and Albei*t himself had had scarlet fever at the same time, but had been 
kept altogether apart from the others until all were considered to have 
recovered. There had been other previous cases of diphtheria and 
scarlet fever at Boehampton, some of them in the families of persons 
living and working in the same estate as the father of these children. 
On June 2 the rooms in which the diphtheria patients had been were 
fumigated with chlorine, and the bedding was stoved in the disin- 
fecting oven of the Wandsworth Board of Works. For a day or two 
before his leaving home Albert had associated with his brothers and 
sisters who had had diphtheria. On June 8 he was examined by the 
family doctor, who considered that he might safely be removed. Mow- 
ever, on or shortly after his arrival at Eversholt, he was found to be 
suffering from sore throat, which grew worse, and on June 12 he was 
sent away to another relative at Hinton, near Brackley, Northampton- 
shire, where he died on June 21, the certified cause of death being 
diphtheria. A little girl living in the same house at Hinton also took 
diphtheria a few days after Albert's arrival. 

Another outbreak occurred among Eversholt school-children in 
November. The first case (origin uncertain) in this outbreak was — 

Infection communicated by patient in early stage. — A. G., aged 4, living 
at Tyrrell's End, had had for a few days what were thought to be sym- 
ptoms of an ordinary cold. On the morning of November 23 he vomited, 
but nevertheless went to school that day, though not afteiwards. On 
November 28 his mother, observing white patches on his throat, sent 
for a doctor, who pronounced his illness to be diphtheria. He had a 
severe attack, but ultimately recovered. Three of A. G.'s class-fellows 
{Cases 33, 34, 35), belonging to different families and residing at different 
Ends, were taken ill of diphtheria, two on November 26 and one on 
November 28 ; incubation period three to five days. " The inference 



Diphtheria. 29 

fieems allowable that they may have taken the disease from A. G. on 
the 23rd.» 

Infection from (?) comtents of cesspit; infection communicated by 
jpaiient in ea/rly stage. — ^A third outbreak occurred in February. It was 
traced with great probability to F. F. (Cose 36), aged 8, living at 
Church End within a few doors of the school, who complained of 
sore throat on February 12, but had been ailing a few days before 
with what were thought to be symptoms of a common cold. Although 
so ill that his mother had to sit up with him part of one or two nights, 
he went to school by day up to and on the morning of February 13, on 
which day, the nature of his illness being recognised, he was kept at 
home. Of the five subsequent cases among school-children, four were 
in the same class as this boy — a different class, and held in a different 
room, from that in which the November cases occurred. As to the 
•origin of F. F.'s case, he may, it is suggested, have caught the disease 
by playing with another boy who had sore throat about five weeks 
earlier. A privy cesspit was emptied at F. F.'s home on February 4, 
and the contents left in the yard slightly covered with ashes until 
February 7. 

Persistence of infection in a house, — " The persistence with which 
the contagion of diphtheria is apt," Dr. Parsons writes, ** to attach 
itself to places is well known ; the following is an instance in point. 
In a house at Church End several members of a family had been 
a.ttacked with diphtheria in December, but in the course of January all 
had either recovered or died. The house was subsequently fumigated 
with burning sulphur, the wall-paper stripped off, and the walls lime- 
washed. The floors, which were old and irregular, were washed with 
carbolic soap. Infected articles of clothing were either burnt, washed, 
or fumigated. On Februaiy 8 a daughter came home from service with 
a bad finger, and on February 13 she was taken ill with diphtheria. 
She had slept in a room which had been used by the sick, but which 
had been purified as above described. She had noticed, however, a bad 
smell in the neighbourhood of the fireplace where certain articles soiled 
by the sick had been burnt. Also a piece of list nailed around the 
door-frame to exclude draught had been allowed to remain ; this list, 
which, from its position, would intercept pai*ticles floating in the air 
entering or leaving the room by the chink of the door, was found full 
-of dust." 

xviii. Cases 37 to 39. 

Dr. Blazall'b Report to the L. G. B. on the Prevalence of Diphtheria in 
the B. S. D. of EIngsclere, Hants, May 15, 1884. 

Diphtheria preceded by simple sore throat and so-caUed mumps, — 
Diphtneria probably spread by school attendance; small villages; 
iLgricultural population. Dr. Blaxall assumes ^* the incubating period 
of diphtheria" to be " from two to four or five days." 

The chief outbreak was at Ashford Hill. There was a very exten- 
sive prevalence of measles in a mild form in the June quarter, and 
mumps were also very general, often occurring side by side >vith 
measles. Certain of these cases of " mumps "* were followed by para- 
lysis, and Dr. 6. considers that mumps and diphtheria were present in 
the school at the same time. Scarlet fever had prevailed in 1882, and 

* Several other instances of this conf asion between mnmps and diphtheria 
may be fomid in reports made to the Local Government Board by its inspectors. 



30 Diphtheria. 

Dr. B. found nndotibted evidence of recent attacks. The outbreak 
occurred July 1 — ^5. " Throat affections in one form or another appear 
to have been generally prevalent in the infected localities, not unfre- 
quently accompanying measles, sometimes simple sore throat, with little 
or no constitutional disturbance and of short duration ; other cases ot 
a specific character passing in sequence throagh families, accompanied 
by fever, headache, and general malaise, leaving the sufferers much 
debilitated, and occasionally with voice and vision affected." 

Not infective fov/r days before attack. — At Headley Common, another 
village, only three cases occurred, but there had been other previous 
cases of sore throat and " mumps." S. S. (Case 37), the sister of one 
of these patients with sore throat, was taken ill on July 2 or 3, and was 
first seen by a medical man on July 5, who pronounced the disease to- 
be diphtheria. S. 8. had ceased to attend school as early as June 28, 
but subsequently her two little nieces {Cases 38, 39), who lived about 
three quarters of a mile off, and came to see her one Sunday in July, 
were taken with diphtheria two days after their visit. " If we may 
believe that the^ were infected from their aunt, the escape of all S.'s 
schoolfellows, eighty-six in number, has to be explained by her diph- 
theria not having reached an infective stage on the last day of her 
attendance at the school." 

xix. C<Mes 40 and 41. 

Dr. Blaxall'b Report to the L. G. B. on Diphtheria in the Eastern Division of" 
the Chippenham B. S. D., dated August 23, 1884. 

Infection by unrecognised cases, — A little girl, J. Ck. {Case 40), waa 
taken by her mother to stay at Mr. O.'s house on October 20, 1884. 
Two of G.'s children were at about this time suffering £rom unrecog- 
nised diphtheria. J. Ck. returned home on October 23, was taken 3l 
with diphtheria on that evening (three days after commencement of 
infection), and died on October 28. So far as could be ascertained by 
inquiry of J. Ok.'s mother and of the local medical practitioner, no sore 
throat or diphtheria had recently been existent in the family or neigh- 
bours of J. Ck. 

Infection apparently conveyed hy individual who did no* suffer.^- 
Mr. and Mrs. B. and family exchanged visits with C.'s family, and 
three of B.'s children suffered, one dying. One day, shortly after the 
first child was attacked, Mrs. B. drove five miles to see a Mrs. F.,. 
whose little boy, a year old (Case 41), she took in her arms and 
nursed for a little while. Two or three days afterwards this child waa 
taken ill with diphtheria, and subsequently Mrs. F. was attacked. 
Mrs. B. had not suffered from diphtheria, but she had been in close 
attendance on her sick child, and this casual visit of Mrs. B.'s waa 
apparently the only opportanity of infection to which the F. family had 
been exposed. 

Infection eowveyed hy a convalescent paHeTVt.^^One of C.'s daughters,, 
while convalescing from unrecognised diphtheria, went away to stay 
with her grandfather ; her voice was then affected, and the glands of 
her neck swollen. Shortly after her arrival Miss F., with whom she 
slept, was attacked with typical diphtheria, and three cases of sore 
throat of an indefinite character followed in other members of the 
household.* 

* Ab an illustration of the complexity of questions which may arise in 



Diphtheria. 81 

XX. CiMes 42 to 44. 

Mr. John Spbar'A Report to the L. G. 6. upon a re-inspection of the Registra- 
tion Sab-district of Dartford, and upon the continued prevalence in th& 
district of Diphtheria, dated July 15, 1884. 

Diphtheria and *' sore throat" — In March, 1883, there was a small 
outbreak of diphtheria in the parish of Stone. Three children, Uvin^ 
at houses widely separated, were attacked on March 25 with well-marked 
diphtheria, and on the same day four others sickened of ailments of 
which sore throat and feverishness were the prominent symptoms. 
These children all went to the same school, and on March 21 — four 
days before their seizure — a fellow-pupil had discontinued attendance 
owing to severe sore throat. All the affected children, including the 
last named, were accustomed to take their midday meal at the school, 
usually in the school lobby, their homes being at a distance. Here 
seven children were equally exposed to infection by a child suffering 
firom the early symptoms of a ** severe Bore throat ; " all seven were 
taken ill on the same day with a throat affection, but in three only was 
it distinctly diphtheria. 

xxi. Caises 45 and 46. 

Mr. John Sfeab's Report to the L. G. 6. upon recent Prevalence of Diphtherip 

in th6 Spilshy R. S. D., May 90, 1886. 

Unrecognised diphtheria followed hy diphtheria, — A servant at a farm- 
house in the hamlet of Eau-Dyke complained of sore throat a few 
days before January 25, and died January 27, her death being registered 
as from ''heart disease," though her throat was said to have been 
much swollen. Three days later her mistress was taken ill with 
unequivocal diphtheria, and died after two days' illness. A Mrs. F. 
(Case 45) was at the farmhouse on January 27, 28, 29, and 30, and was 
with the servant at her death. Mrs. F. was ill on January 30, and she 
died of diphtheria on Februai'y 4. Within the next ten days seven of 
her nine children had diphtheria, and six died. 

Another woman {Case 46) nursed the farmer's wife for a few hours 
only on February 1. On the afternoon of February 4 (three days after 
her visit to the farmhouse) she felt poorly with headache and sore 
throat. She had nine children at home ; seven of these were seized with 
diphtheria two days after their mother's seizure, and the remaining two 
a lew days later : all except a baby had the disease severely, but none 
died. The infection may have been contracted by these children 
directly from their mother while she was in a very early stage, or 
indirectly from (?) clothes brought from the infected house. 

xxii. Cases 47 to 49. 

Dr. Gbesswbll's Report to the L. G. 6. on the Prevalence of Diphtheria in the 

R. S. D. of Erpingham, December 7, 1885. 

Short exposwre ; second attack in one individual, — Three children of 

attempting to ascertain the origin of outbreaks of diphtheria, owing to the 
frequency with which the disease is unrecognised, it may be mentioned that 
several of these families occupied large daiiy farms, supplying milk and cream to 
various companies, to whom the farmers were under heavy bond to report the 
presence bf infectious disease; but in the present instances this course was 
mpntctieable^ the nattire of the disease not bmg recognised. 



32 Diphtheria. 

the same family met children of a still infected family on July 31. 
They fell ill as k)11ows. — B., aged 9 (Case ^1\ morning, and M., aged 7 
{Case 48), night of August 6 (six days after exposure) ; G., aged 6 
{Case 49), morning of August 7. The attack was attributed to a *' mon- 
strous nuisance " arising from a large overflowing privy vault, and an 
«lder sister, ap^ed 18, who had had diphtheria seven years before, began 
with diphtheria on the evening of August 7, so that there is some doubt 
whether the infection ought to be traced to the short interview. 

xxiii. Case 50. 

Mr. B. D. Swbeting's Report to the L. G. B. on Diphtheria in the Famham Beg. D. 

Pirbright school was closed during part of the summer of 1882, as 
it was believed to be then playing a part in the dissemination of diph- 
theria ; Mr. Power's investigation confirmed this view. A girl, aged 11, 
residing at an isolated park lodge at Ash, attended Pirbright school on 
June 27, 1882, the day it reopened. She was attacked with diphtheria 
on June 29 (two days). 

xxiv. Case 51. 

Dr. Gbbsswbll'S Beport to the L. G. B. on the Prevalence of Diphtheria in the 

B. S. D. of Glanf ord Brigg, August 7, 1885. 

Infection by child/ren probably a month after attach, — ^A servant girl 
who contracted diphtheria while at her place was sent home while still 
ill at the end of July, or beginning of August, 1884. Shortly afterwards 
her brother, W. M., aged 7, took diphtheria; another brother, R. M.,aged 
11, and the mother also suffered from sore throat. B. M. and W. M., 
though still sufferinfi^ from sore throat, began to attend school when it 
reopened on September 13, after the harvest holidays. They attended 
regularly up to October 3. 

G. H., aged 5| {Case 51), attended school up to September 19, was 
taken ill September 21, and died September 27. Other cases occurred 
among the children on September 28 and October 1, and two on 
October 2. 

Infection conveyed by individtuds who did not suffer, — Two other 
cases occurred in G. H.'s family, and during their illness the father and 
mother went frequently to buy milk of a Mrs. C, who fell ill in October ; 
her husband and daughter were subsequently affected. 

XXV. Case 52. 

Dr. Gbbsswbll's Beport to the L. G. B. on Becurrence of Diphtheria at a farm- 
house at Norton, 1885. 

Infection long persisting in a house, — Prior to March, 1881, no case 
of sore throat, croup, or diphtheria was remembered to have occurred. 
The sanitary arrangements and surroundings of the house, which was 
occupied by the H. family, were bad. In March, M. A., nursemaid, was 
taken ill ; she remained in the house forty-eight hours, was then sent to 
a cottage half a mile away, and died of diphtheria on March 16, 1881. 
K. H., aged 14 {Case 52), sat with M. A. for a few minutes on March 16, 
and on that occasion only ; *' she complained of symptoms of diphtheria 
on the 20th, allowing thus an incubation of about four days." K. H. 
was isolated ; most of the other children were sent away, and when 
convalescent K. H. also went away. She returned in July, and shortly 
afterwards the cook, A. P., was taken iU; she was sent home, and com- 






Diphtheria. 33 

mnnicated diphtheria to several persons, of whom two died. Seven weeks 
after the commencement of her illness A. P. returned, and ** very soon 
afterwards, in September," 0. D., who had replaced M. A. as nursemaid, 
fell ill ; she was sent away, but i^eturned in three weeks (1882). ** A week 
or so after her return the governess took diphtheria," and later the 
father of the family. A few months later, the spring cleaning having 
just commenced, a housemaid, M. C, aged 18, who bad been for some 
years in the house, fell ill. M. C. occupied the same bedroom as M. A., 
A. P., and C. D. M. 0. was not sent away, and recovered in ten days. 
On one occasion the groom helped to move M. C.'s luggage, and a &w 
days after his child, aged 5, was taken ill, and died of diphtheria. The 
groom and his family lived in a new clean cottage. Three children of 
the H. family, aged respectively 9, 3, and 2, subsequently fell ill in 
succession. The latest of these cases occurred in July, 1882. No fresh 
case occurred until soon after the commencement of toe spring cleaning 
in 1883 ; then a servant maid, M. K., who had entered Mr. H.'s service in 
May, 1882, was taken ill. G. H., one of the H. family, had ** a severe 
attack of tonsillitis " in July, 1883. The next case occurred in Sep- 
tember, 1884, when, soon after the commencement of house-cleaning, 
M. T., who had been cook for two years, fell ill of diphtheria. Two 
weeks later, A. S., nursemaid, fell ill, and then, during October, A. H. 
and E. H. The next case occurred soon after the commencement of 
the spring cleaning of 1885, in the person of M. C, who had suffered in 
1882 ; shortly after, another servant had sore throat. Dr. Gresswell, 
in discussing the means by which the infection was perpetuated in this 
house, states — (1) That he was unable to trace connecting cases during 
the intervals in the surrounding villages. (2) That M. C. suffered 
from several attacks of sore throat subsequently to her first attack of 
diphtheria. (3) That B. H., another son of the family, had " been 
always suffering for some years from sore throat,'* though he was not 
at any time recognised to have had diphtheria. (4) That a slop cess- 
pool, which could not be emptied, but soaked away into the soil, and 
had "received washings, no doubt, from many of the diphtheritic 
patients," ventilated into a confined Idtchen yard, and that its contents 
soaked into the wells. (5) On the other hand, that each outbreak 
commenced in one or other of the servants, shortly after the beginning 
of spring or autumn house-cleaning. Great trouble was taken in disin- 
fecting the house, but the carpets, the contents of the mattresses, and 
some of the clothing had not been disinfected. The house consisted of 
two portions, new and old; tbe old portion stood on the bare earth, and 
one room in it, used as a breakfast and school room, had a brick floor 
a few inches below the surrounding level, and generally so damp that 
two thicknesses of carpet were in constant use ; the lower had at times 
become rotten, and friable to the touch. Large quantities of white 
mould accumulated rapidly on the floor, and an offensive smell was 
frequently perceived in the room. The servants' bedroom was in the 
old part of the house ; it was large, but having no fireplace, and only 
one window, its ventilation was deficient. Foot-halt and mouth disease 
had occurred on the farm. About 1883 and 1884 every oat taken to 
the farm died. 



C 



34 Diphtheria. 



zxvi. 

Dr. Simfson'b Report to the L. G. B. on the Preyalence of Diphtheria in the 
Urban and B. S. D. of Shaftesbury, May 15, 1885. 

1^ Infection conveyed hy patient ev/ppoeed to have recovered; sore throats 
persistent i/n a house liabU to floods.— The disease in this district was 
first prevalent in Melburj, a village two and a half miles from Shafbes- 
burj. The primary cases in each family in Melbury were children, and 
all, with one exception, were attending schooL The school opened on 
October 1, 1883, and in a fortnight's time eleven children were away on 
account of sore throat, which ended fatally in one and caused paralysis 
in three. There were eighty-one children at the school, but the sore 
throat occurred only among the children, fifty-two in number, belong- 
ing to Glasses A and B. Of Class A, 12*9 per cent, were attacked ; of 
Class B, 33*3. One of the children who resumed school attendance on 
October 1 was M., a girl who was still suffering from a sore throat 
which had compelled her to cease attendance before the holidays ; this 
child belonged to Class B, and it was chiefly her playmates who were 
first affected. Moreover the only primary case which did not attend 
school was a little boy who, up to within four days of his death, had 
resided in the same house with M. This house was an old mill, much 
out of repair, situate at the bottom of a ravine beside a miUpond, and 
liable to floods. No history of the introduction oF the disease into this 
house could be ascertained, but it was elicited that sore throats had 
been prevalent in the house for two years at least. The house was 
liable to be flooded, the soil had become waterlogged, and the ground- 
floor was so damp that it could only be inhabited for a few months in 
the summer-time ; the walls of this and of the upper floor were wet and 
covered with moulds, and the woodwork rotten. ** On each occasion of 
the floods," Dr. Simpson observes, " the animals as well as the people 
of the mill were attacked with illness. This would indicate some 
common source of infection rather than that the disease was transferred 
from the animals to man, or vice versa. Both the animals and the in- 
habitants of the mill used the same drinking-water, and lived on the 
same waterlogged soil." 

xxvii. 

Dr. Gbesswell's Beport to the L. G. B. on the Prevalence of Diphtheria in the 

B. S. D. of Walsingham, September 24, 1885. 

Infection distributed at school hy a child cowvcdescent from an unrecog^ 
nised attack* — On January 18, 1884, a child, J. W., residing at Ful- 
modestone, was taken ill vdth a " bilious attack ; " she returned to 
43chool on February 25, suffering from general debility, weakness of 
vision, and peculiarities of voice. Owing to defective vision and general 
weakness she was obliged to cease attendance on March 3. Shortly 
after February 25 several other households were attacked almost 
aimultaneously with diphtheria, the first patient in each household 
being a child attending the school. 

Vhronic diphtheria, — ^A monitress at Langham school contracted 
diphtheria from a previous case, and gave up work early in June. She 
suffered from sore throat several times after this date, markedly on 
November 9 or 10, when after a few days' illness she a^ain gave up 
duty. Within a few days of her return after this attack uiree children 
in the school were affected with diphtheria. 



Diphtheria. 85 



xzviu. 



Dr. Gbebbwbll's Report to the L. G. B. on the Prevalence of Diphtheria in the 

R. D. of Mansfield, March 15, 1886. 

Becurrent attacks of dvphtheria and chronic throat iUness, in some 
cases infective, — A girl, ased 16, had diphtheria at Whitsuntide, 1884, 
and Whitsuntide, 1885, the diagnosis on each occasion being made by 
her medical attendant. During the interval she bad occasional attacks 
•of sore throat, and attributed the second attack of diphtheria to catch- 
ing cold. Her house was damp, the cellar frequently contained several 
feet of foul water. No other persons were known to have been infected. 

Two separate households in a court in an isolated part of Sutton 
were attacked by diphtheria ; the only source of infection which could 
be traced was that a child, X., in the same court, and with whom these 
households had dealings, had had diphtheria the year before, and had 
•since suffered from chronic tonsillitis and chronic enlargement of the 
cervical glands. 

xxix. Case 53. 

Dr. Gbbsswell's Report to the L. G. B. on the Prevalence of Diphtheria in the 

R. S. D. of Erpingham, December 7, 1885. 

Diphtheria followed hy chronic sore throat apparently capable of prO' 
dndng diphtheria in others. — (a) In December, 1881, Mr. and Mrs. F. 
and A. P., then aged 11, had diphtheria ; ever since Mrs. P. and A. had 
sore throat whenever exposed to cold. A. had severe sore throat in 
July, 1883, shortly after taking duty as a monitress at Bodham school ; 
this illness was attributed to taking cold, and no infection could be 
traced. Within a few days three children attending the school fell ill 
of diphtheria. One of these children infected among others an elder 
sister, M., who has been subj^t to sore throat ever since. On December 
31, 1883, a Mrs. B. took a child from another village to visit at M.'s 
house. Mrs. B. was ill next day, and the child died of diphtheria on 
January 7, 1884. In April, 1885, Miss J., who lived in a detached 
house near M.'s (also a detached house), and was a friend of M.'s, fell ill 
with diphtheria. M., when seen in April, 1885, had a strawberry 
tongue, the left tonsil was enlarged, and the pharyngeal mucous mem- 
brane was thickened, with hypertrophied follicles. All these three 
persons — Mrs. B., the child, and Mrs. J. — had also been in M.'s house, 
which had not been re-papered since its invasion by diphtheria. 

(&) In 1879 H. W. ha!d diphtheria, and his mother, two brothers, 
and a sister suffered later. The next year H. fell ill a^ain of 
diphtheria and died. Shortly afterwards J. W., aged 2, had diphtheria 
severely, and ever since, whenever he caught cold, his tonsils swelled, 
and became covered with a white coating. In Au^st, 1884, when 
seven years old, J. played truant and returned to school wet and iU ; 
next morning he was proiiounced by his medical attendant to be suffer- 
ing from diphtheria. 

(c) Mrs. D. had diphtheria in 1868, and ever since had had sore 
throat, large tonsils, and headache after exposure to cold. For six 
years before 1882 she had a yearly attack of quinsy, and since the last 
had suffered every three or four weeks from tonsillar enlargement. In 
August, 1884, she was disabled by a severe attack of "tonsillitis," 
which was probably diphtheria ; whether she was exposed to infection 
by diphtheria was not positivdy known (but she kept a shop). On 



36 Diphtheria. 

December 8 she engaged M. F. to assist her. On December 19 M. F. 
went home with £phtheria, and died December 24. Two weeks 
later her brother had diphtheria. Mrs. J. visited Mrs. D. in November^ 
and fell ill with diphtheria two days after (Case 53). Mrs. B. visited 
Mrs. J., took diphtheria (in December), and gave it to her husband. 
T. F. also visited Mrs. J., took diphtheria, and died. Mrs. D.'s house 
was small and damp, and there was a large offensive privv vault in 
contact with the kitchen wall. Mrs. D.'s two children (as^ed 3 and ll)* 
and her husband did not suffer from sore throat ; the children were 
isolated when she was ill. 



Br. Gsesswell'b Report to the L. G. 6. on the Prevalence of Diphtheria in the 

R. S. D. of Glanford Brigg, August 7, 1885. 

Diphtheria and suppvrative tonsillitis. — The reporter brings evidence 
to show (1) that suppuration and diphtherial manifestations may appear 
in the tonsils side by side ; (2) that persons suffering from suppurative 
tonsillitis are peculiarly prone to catch diphtheria after very slight 
exposure. In one case. A, D. returned on October 27 to her home, a 
school at which a child was attending from a house infected with 
diphthei*ia. A. D. had suppurative tcmsillitis within a day or two of 
her return, the abscess burst on November 5, and next day she was 
pronounced to have diphtheria. In another case, Mr. O., subject for 
many years to quinsy, had suppurative tonsillitis, and a few days later 
other cases followed in his family. His daughter, who lived at home, 
was a teacher in a school where several children were in attendance 
from houses infected with diphtheria. In a third case Mr. S., subject 
for years to quinsy, had suppurative tonsillitis ; the abscess burst, but 
his thi*oat was soon ** as full as ever again," and later he had diphtherial 
paralysis : he was living next door to diphtherial patients. 

xxxi. Cases 54 and 55. 

Dr. Simpson's Report to the L. G. B. on the Prevalence of Diphtheria in the 
U. and R. S. D. of Wellington, Somerset, May 23, 1885. 

Infection apparently conveyed by persons who did not suffer. — L., a 
girl aged 14, visited a friend who was attacked a few days after with sore 
throat, and who gave decided diphtheria to another family. L. returned 
to her home on September 25. This house was a cottage on marshy 
ground, with an open well liable to contamination, and a large cess- 
pit. On September 26 L.'s'brother, aged 10, and sister, aged 9 (Cases 54 
and 55), became ill with headache and sore throat, and died in four and 
six days respectively. Other members of the family were subsequently 
attacked. J., aged 16, came home and slept for two nights with a 
sick brother ; he did not suffer, but a few days after his return to work, 
at some distance, one of the family with whom he lived was seized with< 
an affection of the throat. 

xxxii. Case 56. 

Dr. Gsbsswill's Report to the L. G. B. on the Sanitary State of the Aylesbury 
U. S. D.« and on Diphtheria there, July 15, 1886. 

Infection probably during a relapse; diphtheria followed by infectious 

sore throat. — The following is the history of the epidemic investigated. 

(a) In February, 1885, a girl returned home who nad had diphtheria in 



Diphtheria. 87 

the previous month while in service ; she had a relapse, and was inva- 
lided until June. Her brother had sore throat shortly after her return, 
other members of the family had sore throat later, and the house was 
not disinfected. 

(b) In February, 1885, there was a death from croup in Bilston 
Boad, in which most of the children attending St. John's school lived, 
■and there were two cases of diphtheria at a house near this school in 
May, 1885. When this school reopened on August 31, 1885, the head 
mistress noticed that a dozen or more children were suffering from 
throat mischief, with in some instances a considerable degree of 
malaise, and that for four or six weeks after the reopening other 
children, in all perhaps thirty or forty, suffered in like manner, chiefly 
among the girls in the upper schoolroom, who numbered 103. The head 
mistress considered the affection catching, and herself " took it," and 
suffered on and off for about three weeks from ** an ulcerated sore 
mouth with ulcers all over the roof of the mouth." 

(c) The first recognised case of diphtheria was a girl, F. B., attend- 
ing the British schools, but there was a considerable amount of com- 
munication between the children attending the two schools. The 
servant girl mentioned in (a) lived two doors away from F. B»., and 
there was frequent communication between the two families. F. B. 
was taken ill while at school on October 18, and died October 24. 

(d) One of the mistresses (Case 56) at the British school visited 
the R.'s on October 28th, and kissed the corpse of F. B. She fell ill of 
sore throat on October 30. But two of F. B.'s sisters continued to 
■attend school up to October 23rd, and the next two cases occurred in 
school-children who fell ill on October 31st and November 2nd respec- 
tively. The mistress continued at her duties until she fell ill. 

The epidemic spread to other schools, and was not extinct at the 
end of February, 1886, when the inspection was made. The sanitary 
•condition of the town was very defective. 

xxxiii. 

Mr. Geobgb Tubnbb's Keport to the L. G. B. on Diphtheria at Dalham, 

1886 (unpublished). 

Fomites ; long persistence of infection. — Mr. Turner mentions a case 
which had come to his knowledge in which the infection of diphtheria 
had been preserved in clothes for four months, and quotes account 
igiven by Dr. Armstrong, M O.H., of the occurrence of diphtheiria in 
two families in June, 1885, and in June, 1886, which appeared to favour 
the opinion that the infection might be continued in some way in a 
family for a year or more, and carried by it into another village on 
moving from one to the other. 

xxxiv. 

Mr. Gbobob TtTBNBB's Ileport to the L. G. B. on Diphtheria in the village 

of Farnborough, 1886. 

OravUy of disease depending on existence of nuisances in houses, — 
''< Only one death [out of ten] occurred in a house in which serious 
sanitary defects were not discovered. In fact, as far as the epidemic 
in this village is concerned, the gravity of the disease has chiefly 
depended upon the presence or absence of privy nuisances." 



88 Diphtheria. 

XXXV. 

Dr. Gbbsbwbll's Report to the L. G. B. on Diphtheria at the Royal Female 
Orphan. Asylum, Beddington, April 2nd, 1886. 

History of endemic prevalence of " sore throat," " tonsillitis/' &c^ 
with occasional cases of recog^nised diphtheria. 

xxxvi. Cases 57 to 60. 

Mr. Gbobge Tubvbb'b Report to the L. G. B. on Diphtheria in Monlton, 

Novemher, 1886 (nnpuhlished). 

School influence. — ^The reporter had little doubt that the over- 
crowded chapel Sunday school was principally responsible for the ease 
with which the epidemic spread . It probably obtained entrance through 
a girl, L. S., who did not attend, but lived next door to the school. 
This girl was sickenine with diphtheria on June 7, a Sunday. The 
next cases occurred as follows : 

On June 10 M. B. {^Case 57), a girl aged 15, L. S.'s cousin, had been 
in communication with L. S. recently, probably especially on June 7. 
Incubation period probably three davs. 

June 11. — W. B. {Case 58), brother of M. B., aged 13; incubation 
period probably four days. B. B. (Case 59), brother of M. B., aged 9 ; 
incubation period probably four days. A. W. {Case 60), a girl aged 6,. 
belonging to a family in which L. S. was nurse ; incubation period pro- 
bably four days. 

Other cases followed in the B. and in other families in which the 
mode of infection was not traced ; but the reporter points out that in 
the week following Sunday, June 21, a series of cases occurred among 
children attending the chapel Sunday school, viz. : 

June 23. — M. S., f. a^ed 18, incubation period two days, probably. 
S. B., m. aged 13, incubation period two days, probably. F. P., aged 8^ 
incubation period 2 days, probably. E. F., m. aged 8^, incubation 
period two days, probably. 

June 24. — M. B. and £. B., sisters of S. B., incubation three days^ 
probably.. 

June 25. — A. F., sister of F. F., incubation period four days, 
probably. 

All or most of these children were attending on week-days at the 
National schools, in which several cases of diphtheria had occurred 
before June 21. 

xxxvii. 

Mr. Geoboe Tubkeb's Report on Diphtheria in Petersfield and the neigh- 
bourhood, 1886 (unpublished). 

Infection by person who did not suffer, — ** The infection may have 
been conveyed in many ways. In one instance the mother of a family 
assisted in laying out one of the children who died. She does not 
appear to have suffered, but her children did." 

? Infection ca/rried by a person who did not suffer until later, — ^A lady 
landed at Portsmouth from Malta on January 4, 1886, and next day 
went to a house at Grantham. This lady had sore throat on January 10,. 
but it was at first slight, so that she was not seen by a medical man 
until January 15 ; on January 16 he diagnosed diphtheria. She had 



Diphtheria. 39 

post-diphtherial paralysis, but eventually recovered. The master of 
the house, aged 73, had sore throat January 26, and died February 4. 
His daughter, aged 23, had sore throat February 5 or 6. and died, after 
tracheotomy, on February 13. In discussing the origin of the specific 
infection in this case, the reporter states that there was no diphtheria 
on board the vessel ; the lady, L. S., must have been infected either (1) 
on the journey from the docks to Gi*antham, or (2) at the house in 
Grantham. In support of the latter hypothesis it is pointed out that 
the daughter, a^^ed 23, who suffered last, was known to have visited 
certain cottages in Grantham Forest, where two fatal cases of diphtheria 
had occurred. " Is it not probable she may have been the person who 
introduced infection into the family, although she herself did not pre- 
sent sufi&cient symptoms to attract attention until so much later ; and 
that until her system had been afiEected by trouble and anxiety she had 
been able to resist the disease P The nature of the case renders direct 
proof difficult, but so many instances have come to my notice in which 
diphtheria appears to have been commenced in this manner that I 
think it may be probable." 

xxxviii. Cases 61 and 62. 

Dr. Pabbons' Report to the L. G. B. on the recent Prevalence of Diphtheria in 

the Wincanton B. S. D., &c., July 31, 1886. 

Incubation periods of not less than seven days, — Several cases of diph- 
theria occurred among children attending Queen Camel school, which 
closed on August 14, 1885. Four cases subsequently occurred, one in 
the village on August 16, and three at Camel Hill, a mile away, two 
{Cases 61 and 62) on August 21, and one a day or two later. '* On the 
supposition that the diseases were contracted at school, the incubation 
period of the Camel Hill cases would be at least a week, or perhaps 
more, whereas the usual period is two to five days." 

xxxix. 

Mr. W. H. Poweb's Report to the L. G. B. on an Outbreak of Diphtheria at 
York Town and Cainherley (parts of Frimley parish), in the Famham R. S. D., 
April 7, 1887. 

Milk epidemic ; large milk consumers attacked in greater numbers, — 
The reporter concluded that the outbreak of diphtheria was due to 
milk which had acquired the quality of infectiveness before leaving the 
dairy farm where it was produced. There was a verv different inci- 
dence of the disease upon the wealthier class and the class of cottagers 
and tradesmen, the former suffering much more than the latter. The 
following table shows the incidence on families of the several classes 
residing within the area selected for investigation, and supplied with 
milk from the dairy farm in question : 



Number of funilies 


Number of 


Invasions 


supplied with the milk. 


families invaded. 


per cent. 


Wealthier class . 44 


87 


840 


Cottagers and tradesmen 50 


11 


220 



The following table shows the incidence on individuals, members 
of the families enumerated in the above table : 



40 



Diphtheria. 



Wealthier 
class 

Cottagers 
and trades- 
men . 


Children (0—16 yean). 


Adalta. 


Allagei. 


ToUl. 


Attacked. 


Total. 


Attacked. 


Total 


Attacked. 


No. 

26 

6 


Per cent. 


No. 


Percent. 


No. 


Percent. 


48 
94 


64-1 
6-4 


269 
145 


79 
9 


29-3 
6-2 


317 
239 


105 
15 


331 
6-3 



The amount of milk supplied to the two classes of families differed. 
The average amount to the wealthier households was 5*2 pints to each 
household daily ; in the other class the dailj average was 0*8 pint to 
each household. Further, within the same class of households treating 
their milk in the same manner there was still to be discovered a differ- 
ence of diphtheria incidence according to the mere amount of milk 
consumed by the individual. Thus, as regards adults amons^ the 
wealthier class, *' of 217 adults in 41 households described as not being 
special milk drinkers, 60 (27*6 per cent.) were attacked; whereas of 
other 32 adults in 21 of the households, who were considerable con- 
sumers of milk, 25 (780 per cent.) were attacked." As regards children, 
" Only 10 children in 8 households are recorded as not consuming 
much milk, and of these no more than one was attacked. But of 3B 
other children in 18 households, who did consume milk in considerable 
^[uantity, 23 (70*0 per cent.) were attacked." Further, " the differing 
incidence of diphtheria upon milk consumers of one and another rank 
of life was considered to be very probably due in some measure to a 
difference in the customary treatment of milk after its reception into 
the houses of the one and the other class. Thus the cottager and 
tradesman class did not as a rule keep milk from one delivery to 
another, or overnight, whereas in the wealthier households it was 
generally the practice to store up milk, often several pints together, for 
a greater or less number of hours or overnight. In eleven households 
in which skim-milk had been consumed the incidence of diphtheria on 
both adults and children was heavier than in any other group of 
households of similar size; further, fourteen households of the wealthier 
class, that denied having kept milk of any sort from one day to another, 
suffered less diphtheria in their adults and in their children than any 
other group of equal size of the wealthier class.'* Mr. Power, however, 
adds the caution that these households consumed comparatively little 
milk, and few of them contained many children or milk-drinking adults. 
Mr. Power, in concluding his report, makes the following observations 
of importance in connection with the origin and spread of epidemics of 
diphtneria among the inhabitants of villages, who, as a rule, consume 
only small quantities of milk : — *' The diphtheria among wealthier class 
consumers was, as regards amount and fatality, so conspicuous that its 
relation to the milk service was readily seen, but amone poor class 
consumers it was so inconspicuous in amount and fatality that the 
fact of its relation to the milk service might readily have been over* 



Diphtheria, 41 

looked. It is altogether donbtf nl, therefore, whether, in the absence of 
tbe test of the milk supplied in the persons of wealthier class con- 
sumers, the ability of this milk service to cause diphtheria would have 
been detected." 

xl. Cases ^ to 67. 

Dr. Aiby's Report to the L. Q. B. on an Epidemic of Diphtheria at Buxted and 
Maresfield, in the Uckfield R. S. D., July 3, 1888. 

Infection conveyed hy convalescent patient. — The first cases were two 
children named M., whose parents kept a roadside inn. Tbe boy, aged 
11 {Case 63), went to stay in Buxted village, about two miles from the 
inn, on September 19. He walked home on September 26, and on his 
arrival about 5 p.m. his father noticed the bad smell of his breath, and 
saw that he was ill, and went at once for a doctor, who came next day. 
The little girl, aged 9 ( Case 64), had seemed sleepy and out of sorts for 
a day or two before, and on the Sunday evening, September 26, she 
seemed ill like the boy. On Monday the doctor found them both 
suffering from diphtheria. They both recovered. There appears to 
have been no doubt as to the nature of the disease, but the source of 
infection was not ascertained. It can hardly be doubted that the two 
children must have contracted the disease from one and the same cause 
at the same time, while they were together on or before Sunday, Sep- 
tember 19. The girl,* when convalescent (about three weeks from the 
date of the attack), went to stay at the same house in Buxted as her 
brother had visited before the illness ; soon after her arrival at Buxted, 
a little delicate boy, between three and four years old, a visitor to the 
village, who was known to have been at play with her, though only out 
of doors, sickened with diphtheria on October 21, was taken home 
on October 24, and died on October 28. On the day of his death a 
younger child of the same family was taken ill, and died on November 1. 
This family lived within a mile of the village, at a small farmhouse. 

Infection conveyed hy children who did not suffer. — ^Two of the M. 
children, aged 7 and 5, who had escaped diphtheria, returned to school 
(at Hurstwood) on October 25. On October 31 a boy aged 14 (Ca^se 65), 
attending the same school, was taken ill. He had met the two M.s, and 
they had given him an apple. He was the son of a gamekeeper, living 
in one of a pair of new houses in an out-of-the-way spot. 

Probable conveyance of infection by patient in incuboHon stage. — Five 
Ash Dovm is a cluster of houses two miles from Hurstwood and a mile 
from Buxted. At both of these villages there had been diphtheria, and 
some of the Five Ash children went to Buxted school. One family. P., 
attacked in April, 1887, almost simultaneously with the other Five Ash 
families, however, sent their children to Maresfield school, a mile and a 
half in the opposite direction to Buxted. Within two days after the 
first attack in F.'s family, a boy named C, living in Maresfield village 
and attending Maresfield school, was taken ill. It was noted that he 
sat in school next to one of the P.s, but not the one who was first 
attacked. If G. caught diphtheria through the P.s, it must have been 
during the incubative period of the latter. The possibility that the 

* It is worthy of note that the boy went to stay with hia grandmother^ and 
slept with a sister who was staying in the grandmother's house, but neither 
this sister nor any one else in the house took ihe disease. 



42 Diphtheria. 

infection may be conveyed in the clothes of these children cannot be 
altogether rejected. 

Infection preserved in clothes, — With the exception of one case in 
October contracted elsewhere, there had been no diphtheria in Five 
Ash Down from May to December, 1887. In December a family of 
delicate children, living next door to — and under the same roof with — 
a family that had suffered in April and May, was attacked with diph- 
theria. It was naturally supposed that this was in some way a revival 
of the old infection, and on inquiry Dr. Airy found that some clothing 
from the previously infected .house — clothing that had belonged to 
victims of the disease — ^had been purchased by the neighbour whose 
children were afterwards (though not till some weeks afterwards) 
attacked with diphtheria. 

Infection hy short interview toith convalescent patient; incubation 
period six days, — The schoolmaster at Maresfield (Caae 66) had an 
attack of the disease in November. There was no infection, so far as 
is known, among the school children or in their homes at that time. 
The only explanation that could be offered was that six days previously 
he had met in the open road, and patted on the shoulder, a boy who> 
had been ill in the latter part of October, and was just beginning to* 
get about again. 

An outbreak occurred in August, 1887, at Heron's Ghyll school, on 
the high road about two miles beyond Five Ash Down and 200 feet 
higher up towards the forest. The first family attacked resided in an 
out-of-the-way cottage, situated in a hollow near a brook. A week 
previously the child— a girl aged 13 {Case 67), who was the first 
attacked — had been to Hurstwood, where there had been diphtheria, to 
a little general shop there, but it was not known that any case of the 
disease remained in Hurstwood at that time. 

xli. 

Dr. Aibt's Report to the L. G. B. on an Outbreak of Diphtheria at Haslemere^ 

in Surrey, &c., August 12, 1887. 

Example of transmission hy unrecognised cases, — There was diphtheria 
at Shotter Mill school during and after January, 1886. Two families; 
Brown and Smith, resided in adjoining cottages at Olay Hill, halfway 
between Haslemere and Shotter Mill. The Brown children went daily 
to Shotter Mill school, the Smith children to Haslemere school ; the 
children of the two families were often together at home. One of the 
Brown children was attacked in May, and died on May 25 ; another 
sickened later, but recovered. Some time in June the Smith children 
sickened with similar sjrmptoms (the mother said) to those of the 
Browns, especially vomiting and headache ; one of the Smith children 
was in bed three da^s, the other one day. *' A doctor was called in, 
who (the mother said) at first thought the children had diphtheria, but 
afterwards, when they speedily recovered, ascribed the sicxness to the 
heat of the sun/' Smith's children went to the Haslemere infant school^ 
and " the first undoubted case of diphtheria in Haslemere was that of 
a pupil-teacher at that school, who remembers the fact of one of the 
Smiths having sore throat. She was taken ill on July 4." 



Diphtheriu. 4$ 

zlii. Cases 68 to 70. 

Dr. PABSOifS' Report to the L. G. B. on the recent Prevalence of Diphtheria in 

the city of Winchester, April 25, 1887. 

Infection through a common drinking vessel, — X., a man employed at 
a workshop, had a sore throat and stayed at home for a few days. On. 
the day of nis return to work his employer asked him and two other 
men (Cases 68 and 69) to help in carrying a cask of ale into the house, 
rewarding them with a mug of the liquor between them, of which X. 
drank first, followed by the two other men. Both of these latter were 
taken ill two or three days later, and one of them had a distinct attack 
of diphtheria, followed by paralysis of the soft palate. 

A little girl came from a town where diphtheria was prevalent to- 
Winchester, and was taken ill next day with diphtheria. A week later 
her mother, who came with her, and a servant {Case 70) of the house- 
hold to which she was on a visit (both of whom had nursed her), were 
taken with the same disease. 

Epidemic sore throat in a school succeeded hy diphtheria. — Three 
children. C, who had had ''colds/' attended a school at its re- 
opening on September 14. On September 22 A., a little girl attending 
the same school, stayed away from school on account of sore throat. 
She returned on October 4, and a few days after this the schoolmistress 
noticed that A. and two of the G.s were suffering from an affection of 
the eyesight, which, she said, " seemed to be infectious." This affection 
was found to be paralysis of accommodation. B., a great friend of 
A.'s, was taken ill on October 16 of undoubted diphtheria, followed by 
inability to see near objects. Other cases of " sore throat " followed in 
A.'s family. In another instance a child who died of diphtheria was- 
probably infected by another who had no medical attendance, but had 
been feverish, with dysphagia and white spots in the mouth. 

xliii. Case 71. 

Mr. Spbab's Report to the L. G. B. on the continued Prevalence of Diphtheria 

in the Aylesbury U. S. D., December 15, 1888. 

Two outbreaks of diphtheria connected by prevalence of sore throat. — 
Thisreport deals with the reappearance of the disease after nine months'* 
interval of almost entire freedom, and is in continuance of Dr. Gress- 
well's report of 1886 (see No. xxxii). Mr. Spear found the endemie 
prevalence of diphtheria in Aylesbury* co-existed with a condition of 
sewers and drains that was productive of excessive filth contamination 
of soil and air. The epidemic which began in 1885 continued after 
Dr. Gresswell's report, but extended very slowly after March. From 
July 15, 1886, to April 11, 1887, no fatal case of diphtheria occurred, and 
only three non-fatal cases could be heard of; one of these occurred in 
August and two in October. The fact of this intermission could be- 
affirmed as regards recognised diphtheria, but " simple sore throat** 
had prevailed throughout the winter of 1886-7; catarrhal rhinitis, 
likewise, with some offensive discharge, was stated to have been common 
during this period. As to the diphtherial nature of the catarrhal 
affections that were thus intei*posed, Mr. Spears writes, " The absence 
throughout a long series of cases of the distinctive appearances of 

* Deaths from diphtheria in Aylesbury : 1880, 0; 1881, 1 ; 1882, 2 ; 1888, 1; 
1884^ ; 1885, 15 ; 1886, 16 ; 1887, 27. 



44 Diphtheria. 

diphtheria, the freedom from fatality and from characteristic sequelae, 
must be aDowed weight. On the other hand, when diphtheria preva- 
lence was again established, althoueh that of ' simple sore throat ' had 
been diminished, several cases of illness occurred, not distinguishable, 
it is said, from the apparently simple affection, except for characteristic 
sequelsB ; and here and there unequivocal cases of diphtheria were asso- 
ciated, apparently causally, with attacks that from a clinical standpoint 
alone would be considered non-specific." 

The clinical features of the^e cases of sore throat did not differ 
from those of erythematous or follicular tonsillitis. The small white 
or yellowish specks on the swollen and h3rper8Bmic mucous membrane 
of one or both tonsils, common to that affection, never, it was said, 
assumed the appearance of the thick continuous membrane of developed 
diphtheria, and disappeared after one or two days' duration; slight 
follicular erosions of the tonsils were frequently seen. The lymphatic 
glands were often enlarged and tender, and for a day or two constitu- 
tional disturbance was present. Albuminuria, in the few cases in which 
it was looked for, was never observed. General debility of some dura- 
tion frequently followed these attacks, but distinct paralyses were 
absent. Children and young adults were attacked in largest propor- 
tion, and occasionally several members of a family suffered simulta- 
neously, or more often in rapid succession. 

Diphtheria in 1887-8 tended to recur in the same localities as had 
been infected in 1885-6. In the first epidemic the streets contributing 
the total mortality contained 529 houses, or an estimated population ot 
2710, so that the death rate was 11*4 per mille of the street popula- 
tion ; in the second epidemic the mortality rate was equal to 6*3 per 
mille of this population, whereas in the remaining streets the corre- 
sponding ratio was 2*3. Further, diphtheria tended to recur in the same 
houses. *' Nine houses invaded during 1885-6 were again, in the outbreak 
of 1887-8, the seat of disease. In other words, estimating the number 
of infected houses in the first outbreak at eighty,* even at this high 
computation their inmates suffered during the recent epidemic more by 
60 per cent, than the rest of the inhabitants of infected streets, or to 
somewhat more than twice the extent of their fellow-townspeople 
generally. Again, during the progress of the last epidemic the disease 
made its appearance twice, by two apparently separate and distinct 
invasions, in eight houses the interval between the first and second 
ranging from three to ten months (in three cases, three to four 
months ; in three, four to five months ; in one, six months ; and in one, 
ten months). Before the second appearance of the disease the house 
had in each case been apparently free from infection for some weeks at 
least. In ten cases the disease was found to have made its appearance 
next door to houses invaded during 1885-6. In two of these cases, 
however, the disease had meanwhile reappeared in the house next door 
{the one invaded in the earlier year) ; the interval between the second 
invasion of the one house and the first of the other being, in the two 
oases, five days and four months respectively." 

No evidence of family predisposition was obtained which would serve 
to account for these recurrences ; and as to individual predisposition, in 

* As only thirty-seven houses are known to have been infected down to 
Febniary 21, 1886, by which time six tenths of the mortality had occurred, this 
estimate is prohably too high. 



Diphtheria, 45 

only one case did the disease start definitely a second time in the 
person of a previous sufferer. The reappearance of the disease in these 
nouses, therefore, was not due to persistent cases of chronic diphtheria. 
Mr. Spear writes, " The histories I have obtained lead me to believe 
that chronic cases, or cases attended by relapse so as to cover a long* 
period of time, and at last perhaps proving fatal, may occur ; but in 
the instances of * recrudescence ' * I have given such explanation was» 
I think, sufficiently excluded." 

Incubation period of five days. — At Oving a girl aged 14 (Oflwe 71) 
" sickened with diphtheria on November 13, 1887, and died on the 24th ; 
her brother was seized on that day, and died on the 30th. The medical 
man in charge of the cases after perfoi*ming tracheotomy was likewise 
attacked. No other cases of diphtheria were known of in the neighbour- 
hood. The first sufferer had for some time only been away from home 
once, and then to a tea party held on November 8 in the Goi*n Exchange, 
Aylesbury, i. e. five days before definite symptoms of infection were 
observed." 

Infection conveyed by unrecognised caae, — At Weedon there was a good 
example of conveyance of infection by an unrecognised case. A boy 
attending school at Aylesbury had a bad cold, with foetid nasal dis- 
charge, but received no medical attention. Before he recovered his 
sister sickened and died of diphtheria in four days. 

xliv. 

Dr. Bbuce Lowb*b Report to the L. G. B. on Epidemic Diphtheria in the Enfield 

U. S. D., April 28, 1888. 

Milk epidemic. — " The complete indifference to locality here shown 
by the diphtheria as regards its exceptional incidence on consumers of 
the particular milk, and its fatality to such persons when attacked, 

accord with previous experience of milk diphtheiia Of 

51 cases reported, over 80 per cent, had been taking this milk, as also 
had every one of the cases which proved fatal." Of about 210 houses 
in a particular area taking the milk 21, or 10 per cent., were attacked ; 

* Mr. Spear gives the following instance of recrudescence. In Northern 
Road (a small private street of twenty-three houses, in which five cases of 
diphtheria and two deaths had occurred in the epidemic of 1885-6) two children 
of one family fell ill during the first week of May, 1887. They were both 
attending the British school, but only one case of diphtheria, and tiiat a month 
earlier^ had up to that time occurred amongst their schoolfellows. The children 
recovered; and on June 6 were both attending school again. On September 23 
another child of the f amily^ not attending school, was attacked by diphtheria. 
I could hear of no exposure to infection since her sister's illness, nor could I learn 
on careful inquiry of any other case in this street during the interval of some 
four months that had elapsed. A fortnight later a young child of another 
family in the row sickened, and died after five days^ illness. The house first 
invaded was apparently free from infection once more^ and the school children 
were again attending school, when, about November 8, the baby, aged 18 months,, 
sickened ; another child, aged 4, not attending school, was seized on November 12 
and died on November 23. A child belonging to another family in the road^ a 
pupil at the British school, fell ill on the 2l8t of the month, l^e house where 
these recurring outbreaks occurred is, it may be remarked, damp, and, owing to 
drainage defects, exposed to sewage effluvia ; the street itself is unmade, sloppy^ 
and neglected. 



46 Diphtheria. 

•of about 690 in tbe same area not taking the milk 5, or 0*72 per cent., 
were attacked. 

Cats. — A little boy bad a fatal attack of dipbtberia. ^ On tbe first 
day of bis illness be vomited, and tbe cat licked tbe vomit on tbe floor. 
In a few days (and after tbe deatb of tbe boy) tbe cat was noticed to be 
ill, and ber sufferings being so severe and similar to tbose of tbe dead 
boy tbe owner destroyed ber. Duidng tbe early part of its illness tbis 
cat was let out in tbe back yard ; a few days later tbe cat of a neigbbour 
wbo lived a few doors off was noticed to be ill. Tbis cat also bad been 
out in the back yard at niebt. This second cat recovered, being carefully 
nursed by four little girls, all of whom developed diphtheria. There 
was no other known source of infection to which these girls bad been 
exposed but their cat. 

xlv. 

Mr. Sfeab's Report to the L. G. B. np6n the Prevalence of Diphtheria in Fam- 

ham B. D., &c., April 23, 1889. 

Infection corweyed hy patient two and a half months after aJttack.^A. 
long series of cases of diphtheria occurred amon^ children attending 
Sansbury Green school, m which insanitary conditions existed. The 
summer holidays commenced on June 30. Within a day or two of 
this date one of the school children, who lived in an isolated cottage 
two miles away, sickened with diphtheria. About the middle of 
September tbis child was sent to a little school at Warsash, two miles 
from her home in tbe opposite direction from Sarisbury. Another 
pupil at Warsash, a companion of the child, sickened of diphtheria 
about October 1, and subsequently four other families in the village 
were infected. 

xlvi. Cases 72, 73. 

Dr. Pabsovs' Report to the L. G. B. on the Prevalence of Diphtheria in Kilk- 
hampton, in the Stratton R. S. D., Cornwall, September 6, 1888. 

Diphtheria ^preceded hy a prevalence of sore throats at a neighhovring 
milage^ and accompanied hy prevalence of sore throat in the village itself, 
— In the neighbouring village the cases of ulceration of tonsils with 
glandular swelling were very numerous, but none were fatal. In Elilk- 
bampton twenty-eight cases of sore throat were beard of in the same 
bouses as the dipbtberia cases, or in households in communication 
with them. The diphtheria was in all probability spread in Kilk- 
hampton bv personal intercourse. In several instances the cases of 
diphtheria nad been preceded by cases of sore throat not recognised as 
of specific nature. In two households diphtheria seemed to have been 
associated with scarlet fever, the patients were attacked about the same 
time, and were suspected to have met. In one household '* the first 
case is stated to have begun as diphtheria, having a small white patch 
on tbe tonsil with external swelling; in about a fortnight a scarlet 
rash broke out. A second and third case of diphtheria followed, both 
mild and with no rash. These were followed in two other members of 
tbe family by attacks of scarlet fever without diphtheritic membrane, 
and of one patient tbe skin was still peeling at tbe time of my visit. 
In the other family a servant had had ' ordmary sore throat,' with a 
little redness about tbe tonsils, but no rash. A few days later, a girl 
aged II was taken ill with vomiting, headache, and sore throat; a. 



Diphtheria. 47 

49carlet rash appeared on the third day and was followed by copious 
peeling, but there was also a deposit of diphtheritic membrane on the 
throat. The attack was followed by one of rheumatism. A younger 
child had a slighter attack." In no case in this Kilkhampton outbreak 
were any pararfrtic symptoms noticed. 

Ineiwation supposed to he fourteen days, — In two cases it was locally 
believed that the period of incubation was fourteen days. (1) A boy 
{Case 72) residing in an outlying house spent some part of a day at 
his aunt's house, in which a boy was then lying ill of diphtheria. Four- 
teen days later this child was attacked with diphtheria. (2) In this 
■case (jCaxe 73) there seemed to have been other opportunities of con- 
tracting infection subsequent to the one a fortnight before. 

xlvii. 

Dr. Pabsons' Beport to the L. G. B. on an Outbreak of Diphtheria at Llanara 
and Whitford, in the Holywell B. S.D., October 2, 1888. 

Diphtheria in childrenpreceded by scarlet fever in them, and by sore throat 
in adults, — Five households were invaded, two in January, two in April, 
and one early in May. Only two of the houses were near together, viz. 
one of those invaded in January and one in Apidl. The houses were all 
on high ground, and scattered along a course of about four miles from 
«ast to west. The first four houses invaded were small old farmhouses 
or cottages. The milk supply was different in each case, and in no case 
<K>uld any disease of domestic animals be heard of in connection with 
the cases of diphtheria. In the first house invaded no means were 
heard of by which the disease could have been introduced from else- 
where, but the father, a quarryman, had had an illness attended with 
■some sore throat, but stated by the medical man who saw him to be 
rheumatism ; a neighbour also had had " quinsy," to which he was 
liable. The patients who had diphtheria in this family were children 
who had all suffered from scarlet fever shortly before, and had gone out 
and " caught cold.'* 

Persistence of diphtheria in a family, — The fifth house invaded in 
May was of a different class ; it was a large Hall, two miles from either 
of the others, in an open dry situation. The family had previously 
suffered from diphtheria and lost one child when living in Holywell ; a 
defective water-closet was suspected as having had to do with the out- 
break. In 1884 they removed to the large house above mentioned, and 
thereafter had suffered from time to time, and on some occasions 
43everal at one time, from sore throats characterised by ulcers on the 
tonsils, &c., with sloughy surface and red angry base, or occasionally 
small patches of false membrane; one little girl who had enlarged 
tonsils was most frequently affected. In June, 1885, this little girl 
had a distinct attack of diphtheria, as also did another daughter in 
May, 1888. At the latter date, and also in the previous December, 
several other members of the family suffered from sore throats of the 
kind previously mentioned. On examining the house the drainage was 
found to be ill-arranged. 

zlviii. Case 74*. 

Mr. Spbab's Beport to the L. G. B. on an Outbreak of Diphtheria in the 
Llandissilio Beg. S. D., Pembrokeshire, September 28, 1888. 

Incubation seven days ; infection contracted hy dogs (?) and conveyed 
to children (/).— -An outbreak of diphtheria in an agricultural district. 



48 Diphtheria. 

Importation not traced. Affected chiefly two villages, which were 
almost continuous. At both villages there were gross insanitary con- 
ditions, especially in connection with disposal of refuse and excrement. 
The infection was only active in this the original focus. Gases occurred 
in the small town of Narbei*th, in houses having much better sanitary 
surroundings, and did not spread. All these cases, with two exceptions^ 
occuiTed among people who had visited the infected villages. The fol- 
lowing were the cases in Narberth:— (1) A woman who, a few days 
before her illness, visited an infected family in one of the before-men- 
tioned villages ; she had four children, but neither they nor any other 
member of her family suffered. (2) A tradesman of Narberth (Vase 74) 
visited one of the villages, and was attacked just one week later. (3) A 
servant maid had sore throat a few days before the return of a child of 
the family. The child was attacked with diphtheria a fortnight later. 
(4) Two children of Dr. P., of Narberth, who was daily visiting cases 
in the infected villages. He was accompanied on his rounds oy two 
terriers; these dogs* "attentions to the patients and to the patients*^ 
food supply were so marked as to necessitate, on one occasion at least, 
their expulsion from an infected house." These two dogs subsequently 
exhibited symptoms attributed by Dr. P. to diphtherial infection — 
feverishness, drowsiness, constant efforts to clear the throat, &c. Sub- 
sequently two cats developed similar symptoms. Dr. P.'s two children 
were both attacked on the same day, ** about ten days after the canine 
seizures.'* The two children suffered severely. Dr. P. had "some 
slight sore throat " at a date not specified. 

xlix. 

Dr. Pabsons' Report to the L. G. B. on an Outbreak of Diphtheria at 
Llanwddyn^ Montgomeryshire, October 9, 1888. 

Infection conveyed by bedding. — In speaking of the difficulty of tracing 
or excluding personal contagion, Dr. Parsons states that in two house- 
holds outbreaks of diphtheria followed the use of a bed, given by a 
neighbour, upon which a diphtheria patient had slept. In both in- 
stances this circumstance was first heard of casually from neighbours* 

1. 

Dr. Blaxall's Report to the L. G. B. on an Epidemic of Diphtheria at Mid- 
somer Norton, &c., September 4, 1888, and Annaal Report. 

Infection carried by unrecognised cases. — There had been a good deal 
of sore throat, ulcerative in character and offensive, during the winter 
months, and there had been diphtheria in two neighbouring villages. 
The first case of diphtheria in Midsomer Norton came under care on 
April 30, the second (in the same house) on May 4. The first case was- 
taken ill April 27, and died May 2. In thirteen out of fifteen families 
first attacked the first sufferer was a child at the chapel school, and 
inquiry showed that diphtheria and suspicious sore throat had been in 
the school before April 27. Certain of these unrecognised cases of 
*' suspicious sore throat " subsequently developed paralyses. No com- 
munication could be certainly established with antecedent cases in the 
two other villages, " but," Dr. Blaxall writes, '* it may be a question 
whether these cases of sore throat afford examples of progressive deve- 
lopment of sore throat into diphtheria, which has been spoken of by 
certain authorities. I see, however, no evidence in favour of this hypo- 



Diphtheria, 49 

thesis, observiiig that cases of sore throat, however triyial, are shown 
to be already of diphtheritic nature if they are followed by the charac- 
teristic paralysis of the disease." 

li. Case 75. 

Vr. Aiby's Report to the L. G. B. on a Prevalence of Diphtheria in the Northern 
Outskirts of Norwich, in 1887-8, December 2, 1888. 

Infection probably from n foul catch-pit. —The suburbs of Norwich 
extend into the parisl^ of Oatton. The epidemic in Norwich was 
probably stai*ted and maintained in connection with sewer nuisances. 
Cases occurred towards the end of April, 1888, in Hellesdon Boad. On 
July 10, a lad {Case 75) nearly 15 years old was employed by a cow- 
keeper in the Hellesdon Road to empty out the catch-pit adjoining 
the cow-shed. He was " overcome " by the stench, was ta&en suddenly 
ill, and obliged to go home. He lived at an isolated cottage in the 
open country; his father was a shepherd. Diphtheria developed 
rapidly, and the lad died July 15. A child of four in the same 
family died nine days later. The father and two other children 
had it severely, the mother and two remaining children slig^htly. 
Nothing is stated as to the health of tl^e cows. It was impossible to 
prove that the boy had not contracted the disease before be^pnnin^ the 
work at the catch-pit. Dr. Airy speculates as to the possibility of the 
urinary and fsBcal drainage of a cow-shed becoming the vehicle of the 
poison of diphtheria, and as to the infection of filth heaps and filth 
pools and filthy drains over a certain area serving as the focus in which 
the poisonous influence maintains itself. 

lii. Cases 76 and 77. 

Dr. Passoks' Eeport on a recent Prevalence of Diphtheria in the Parishes of 
Roche and St. Stephens, in the St. Austell R. S. D., Cornwall. 

Variation in length of intubation after exposure under identical dr- 
cumstanees, — There was evidence that the susceptibility to diphtheria 
varied greatly in different persons. Thus in one family in Roche, not 
worse housed than their neighboui's, three out of four of the younger 
inmates contracted diphtheria, and two died ; while in other instances 
a single case only occurred in a crowded family of children. In one 
instance three young girls of different families went out for a walk 
together one Sunday. One of them had just recovered from diph- 
theria, and her throat was still sore. The two other girls (Cases 76, 
77) were both taken ill of diphtheria in the course of the week, one on 
'Tuesday, the other on Thursday. 

liii. Cases 78 to 81. 

'Dr. Pajusonb' Report to the L. G. B. on certain Outbreaks of Diphtheria in the 

Leek R.S.D., StafCordshire, December 21, 1889. 

Diphtheria in a few scattered households in a hiUy, sparsely populated 
district — At Bradshaw all the members of a stone-mason s family 
except the mother suffered. The first case was a child who died 
December 2, 1888 ; a second child began to be ill December 1. The 
three remaining children were taken to an actjacent empty house and 
looked after by the grandmother. One of them (Case 78) sickened on 
December 10. At Wicken Walls the first case was a girl aged II 
{Case 79), who sickened March 18, and died March 30, 1889. On 

D 



50 Diphtheria^ 

Marcb 15 she bad taken refuge, for an hour or more, from a snowsiorrD 
at the house of a Mr. G. In this house was at the time a boy who had 
been taken ill on March 9 with diphtheria. The boy and girl attended 
the same school, but she had not been there for a fortnight on account 
of the bad weather. At Warslow the first case was a gin who sickened 
on August 17, 1889. On August 21— four days after his sister sick- 
ened — ^her brother P. (Case 80) sickened ; the cases were first seen by 
Dr. A. T. Bury on August 22. The boy then had diphtheria, and died 
August 29. The g^l recovered, but had paralysis of pharynx. A little 
girl, L. {Case 81), daughter of a neighbour, had played with P. up to 
the day he was taken ill (August 21), after which she was kept strictly 
apart from that family. She was taken ill August 25 (not less than 
four days after ces8atiop,.«^>ftiXpj>Uure^^ when seen on August 28 
had diphtheria ; she 4^a X)i^8iMl£'^^/V 

Dr. Parsons ^^^^ that *' in all (B^Uiouseholds attacked the 
inmates were livTli^ff^expose3^*fe"~the in^^Wce of grave insanitary 
conditions, and i^^^o^ei^faBtoc£^aa thel first case was a person 
who had possiblj been^xpiseaHo "e infedtion of scarlet fever or 
measles. In som^ofjthe outbreaks a rash, somewhat resembling that 
of scarlet fever, aB^fjAQwedn^f^eeluI^ of the skin, was observed. 
Symptoms of diphu^8mi!T>4'fl2nydys||€M^lp^ several of the cases, in- 
eluding one in which ar^«Ui:ai^..hgiU-a^l^red." 

liv. 

Dr. Aiby's Report to the L. G. B. on an Outbreak of Diphtheria at Great 

Dunmow, dated August 20, 1883. 

Diphtheritic disease and scarlet fever. — During this outbreak there 
was, in at least two localities, a concurrence or confusion of scarlet fever 
and diphtheria. In the ona case the facts are not clear, but in the 
other a servant girl, L., who had caught scarlet fever at Beckenham, 
and had been treated at the Islington Fever Hospital for seven weeks,, 
went home on April 14 to an isolated farmhouse which had been 
converted into two labourers' cottages. The sanitary surroundings 
were bad (farmyard filth, water from a pond). Eight days after her 
arrival— on April 22 — one of her sisters, aged 14!, was taken ill and died 
on April 24, death being certified to be due to " malignant sore throat." 
On April 23 three more of the family, aged respectively 12, 9, and 3, 
were seized with the same complaint; one died April 25, another April 
26 ; the youngest, after apparently being about to recover, relapsed,, 
and died May 4. This death was certified as due to diphtheria, and 
medical attendant the considered that all the deaths were from the 
same disease. A child in the next house but under the same roof had 
sore throat April 24, and rash of scarlet fever April 30, followed by 
desquamation on chest, legs, and arms. A woman residing a quarter 
of a mile away, who came to help in nursing the sick children and 
laying out the dead bodies, was attacked with diphtheria on April 29, 
and died, while sitting in her chair, on May 2. It should be noted 
that there was a simultaneous prevalence of true diphtheria at 
Dunmow, six miles away. 



Diphtheria, 51 

Iv. 

Dr. Pabsons' Supplemental Report to the L. G. B. on the Continued Prevalence 
of Diphtheria and Scarlet Fever in the Sutton -in- Ashfield U. S. D., dated 
May 8, 1888. 

8imultane<m8 prevalence of diphtheria and scarlet fever.— Scaxlet fever 
and diphtheria had for some time existed side by side in Sutton, and 
in some cases the one disease appeared to be contracted from the 
other. In some cases the first patient in a family was taken ill with 
vomiting, sudden accession of fever, red rash, and other symptoms of 
scarlet fever; but other members of the family, taken ill a few days or a 
week or two later, suffered from what was pronounced to be diphtheria^ 
having no red rash, but white patches on the throat, and in one or two 
instances subsequent paralysis of the muscles of the pharynx. In other 
instances the children of neighboui's who had associated together had 
had at the same time, some what was called diphtheria, others what 
was called scarlet fever. One boy who was taken ill apparently with 
diphtheria, having white patches on the throat, after three or four 
days developed the rash of scarlet fever, which was followed by anasarca, 
of which he died. On the other hand, in one family in which four 
members had suffered from scarlet fever inNovember, two children had 
diphtheria in January, viz. one who had had scarlet fever in November 
and one who had escaped ; the cases both of scarlet fever and diphtheria 
were typical. 

Ivi. 

Dr. H. F. Pabsons' Report to the L. G. 6. on the Recent Prevalence of Scarlet 
Fever and Diphtheria in the Thome Registration District, August 8, 1883. 

Simultaneovs prevalence of diphtheria and scarlet fever, — Dr. Parsons 
remarks that the relation of diphtheria to scarlet fever was, during this 
epidemic, very close. He found no room to doubt that the cases recorded 
as diphtheria were correctly so described, and "many cases were 
followed by the local paralysis characteristic of diphtheria." Yet in 
certain cases ** what was called diphtheria appears to have been con- 
tracted from a case called scarlet ^ver, and vice versa : members of the 
same family have suffered, one from the one disease, others from the 
other ,' and in four of the fatal cases the same individual is certified to 
have suffered from both. Throughout the epidemic the type of scarlet 
fever appears to have tended towards throat complications." Thus of 
the 82 latal cases there were prominent throat complications in 20. 
Besides the above there were 5 deaths from " croup " associated with 
scarlatina in other members of the family, 14 from diphtheria, 11 from 
** scarlatina with suppressed eruption," 14 from " scarlatina maligna." 
Seven cases were followed by fatal kidney symptoms, and one patient 
died on the fourteenth day from syncope. "The close connection,'^ 
Dr. Parsons adds, "between diphtheria and scarlet fever has been 
noticed in all parts of the district, and in the practice of various 
medical men. It appeared to me that the disease had tended more to 
assume a diphtheritic character in houses where there were local 
unsanitary conditions, such as defective and untrapped drains, and foul 
privy middens." The following are among the cases given in illustra- 
tion of these remarks : 

(a) E. T., aged 10, of Epworth, died there of diphtheria on November 
29. No other diphtheria at Epworth. Her married sister, whose boi^ 



£2 Diphtherid. 

was ill with scarlet fever, had come to the house several times before 
her ilbiesB. 

(h) In the family of F., at Thome, there were daring April, 1883, 
three cases of diphtheria and one of scarlet fever, viz. (1) A lad 
aged 16, who had diphtheria ; (2) a ^1 aged 2, who died on April 8 of 
diphtheria ; (3) a girl aged 12, who died on April 28 of scarlet fever ; (4) 
a girl afi^ed 14, who recovered from diphtheria, but whose sight was sub- 
seqaently dim. 

(c) A little girl, W., aged 2, had typical scarlet fever shortly after 
associating with a chHd sickening with that disease. This was in 
September, and on November 6 an apprentice, aged 17, of W.'s father, 
who worked in a room into which "W. after her recovery used to come, 
sickened with diphtheria, of which he died on November 13. ELis 
mother, with whom he resided, subsequently suffered from diphtheria 
followed by paralysis of the legs and pharynx. In the house at which 
they lived was a scullery sink with broken bell trap. 

Ivii. 

Dr. Pabsokb' Report to the L. G. 6. on Diphtheria in the Newport Pagnel 

B. D., dated May 12, 1884. 

Special eharacteristica of ** diphtheria'' ctccompammg ecarlet fever, -^ 
In this district an epidemic of very mild scarlet fever was followed 
apijarently by an epidemic of severe diphtheria. In certain cases, 
which occurred, however, for the most part in the winter after diph- 
theria had broken out, the medical men noticed rash, peeling of the 
skin, and other symptoms of scarlet fever, with an exudation on the 
fauces closely resembling that of diphtheria. In these cases paralytic 
sequels were not noti(^, and all recovered, though one boy subse- 
quently died of croup. At the houses in which these cases occurred, 
offensive untrapped or defectively trapped drains were found. As 
further instances of a possible relationship with scarlet fever. Dr. 
Parsons mentions two cases. (1) A girl had scarlet fever contracted 
at school. A few days later her sister, aged 22, had a sore throat with 
white patches and swelling of the glands of the neck, considered to 
have been diphtheria. She had not fully recovered her voice on 
March 20, a month after the attack. In the house offensive smells 
from ill-trapped sinks were complained of. (2) In a row of houses in 
which previously there had been much scarlet fever two cases of diph- 
theria occurred in adjoining houses. Here, again, there were ill-trapped 
fiinks in the houses. In this outbreak the infectious character of 
diphtheria was not well marked. In only three out of the twelve 
houses were there multiple cases ; in four the first case was an adult, 
and it did not specially attack children attending any particular school. 

Iviii. 

Hr. B. D. B. SwBETnra's Beport to the L. G. B. on Prevalence of Scarlet Fever, 
Diphtheria, and *' Fever" in the Sandal Suh-districtof the Wakefield E. D., 
May 21, 1885. 

SimvManeovis prevalence of diphtheria and sca/rlet fever. — " The fol- 
lowing interesting clinical facts are reported to me as having been 
observed during the epidemic by Mr. Mackenzie [at NormantonJ : — (1) 



DipJUheria. 5S 

The co-existence of scarlet fever and diphtheria in the same snbject. 
(2) Gases of undoubted scarlet f ever, with transient but typical diph- 
theritic patches on the tonsils. (3) Diphtheria following scarlet fever 
in the same suliject, and vice versa, but more usuallY the former. (4) 
The two diseases following each other in the same house in different 
members. (5) Different members being attacked coincidently, some 
with one, and others with the other msease." " There were many 
examples of throat illness without exudation occurring as apparent 
links oetween true diphtheria cases. There were also histories of in- 
fection from cases of so-called ' cold.' " 

lix. 

Mr. B. D. R. SwsBTiv&'s Report to the L. G. B. on Diphtheria in Hertfordshire, 

April 24, 1886. 

Animah. — An epidemic in Braughing was mainly due to personal 
communication. The second case was W. P., brother of the first case, 
0. P., the source of whose infection was not traced. There was at 
about this time (December) a highly fatal disease (**snick-ups ") among 
fowls on two fai'ms in the village. W. P. worked at these farms. It is 
suggested as possible that W. P. infected the fowls. In the following 
March two families who eot their milk from this farm suffered from 
diphtheria. Later the foUowing attacks occurred : — (1) A man worked 
at another farm where a similar disease prevailed among the fowls ; 
the family got their milk from the fai*m ; the children visited the farm 
one day, and about a week after, one of them began with diphtheria^ 
and three others had it subsequently. (2) Seven children living on or 
near a farm, and drinking milk from it, had diphtheria in May, June, 
and July. The first to l^ attacked was a baby, who had never been to 
the village where diphtheria was, and drank much milk ; it belonged to 
the family which lived near but not on the farm. This child was ill in 
May, two other children of the same family in June, and the farm chil- 
dren in July. The fowls on the farm had the diphtheritic disease. 

Ix. 

Mr. B. D. B. Sweeting's Beport to the L. G. B. on the Prevalence of Diphtheria 
in the Whixley Sub-district of the Great Oasebum B. D., August 29, 1889. 

Diphtheria and drain cUa/nsing ; diphtheria and sore throat, — '* Once 
established in Whixley, diphtheria, or throat malady that must be 
regarded as essentially diphtheritic, was spread from person to person 
. . . . by people from infected houses meeting together at chapel, 
by children who were suffering from mild and unrecognised attacks, 
termed variously ' bad cold,' * swollen neck,' and the like, playing with 
other children on the village green. . . . Further, a second attack 
in a house, where three months before four cases of diphtheria had 
occurred, took place at a time when the drainage was being recon- 
structed, and foul old brick drains were being taken up." Two 
instances are given of wounds becoming affected. In one — that of the 
medical man, who had a small abrasion only of the finger — there was 
consecutive paralysis. 



64 Diphtheria. 

Case 82* 

Communicated by Dr. W. Squibb (pablished in Epidemiological Soeieiy^s 

TrantaoHonM, vol. iii, p. 588). 

In tlie family of a doctor of medicine a housemaid was taken ill 
with sore throat and fever on July 17, 1874. On July 23 one of the 
two children of the family was sent away. On July 30 the two chil- 
dren, the one at home and the other away from home, were taken ill 
with fever, followed by exudation on the tonsils and fauces. 

Cases 83 to 87. 

Communicated by Dr. Abthub Whitblbgob, Medical Officer of Health to the 

West Riding County Council. 

'* A woman {Case 83) visited a house where a friend lay dead fi*om 
diphtheria, and kissed the corpse. This was the only visit, and the 
only known exposure to infection. The visitor was taken ill five days 
later with diphtheria." 

"A woman nursed a child who died after about a week's illness from 
' croup and congestion of the lungs,' a diagnosis which, by the light of 
subsequent events, was altered (by the medical attendant) to diphtheria. 
A brother of this child became ill about the same day as the nrst case 
died, and he had a mild but distinct attack of true membranous diph- 
theria. The woman who had nursed the first case returned to her 
home when the child died (August 15, 1885) ; her own child {Case 84) 
was taken ill with diphtheria August 22, and died August 28. She had 
not visited her home while nursing the first case, nor had her child 
come to the sick house. No precautions were taken to avoid carrying 
infection, as the disease was not known or apparently suspected to be 
infectious — *only croup.' This is the clearest case of convection of 
diphtheria that T remember meeting with." 

" A series of cases in a household may help to fix a date of maximum 
incubation. Caae 85. A girl, aged 9, became ill with diphtheria on 
June 10, 1885 ; was isolated on June 12 ; considered convalescent and 
allowed to rejoin the household on June 21. The premises were disin- 
fected. All drainage defects had been remedied during this illness. 
Ca^e 86. A sister, aged 6, became ill with diphtheria on June 29, and 
was isolated at once ; isolation ended on July 15. The premises were 
again disinfected. Case 87. An aunt (adult) became ill with diphtheria 
on July 21 ; she was isolated at once and until Au^st 7. Another case 
occurred on August 15, and subsequently a fifth, but the isolation not 
unnaturally grew lax, and the dates are not material. The intervals 
suggest an incubation of about six days. I ought, perhaps, to add that 
a playmate of the first child's, living near, was taken ill with diphtheria 
June 16 ; last contact June 9 or 10." 



ENTERIC FEVER. 

THE difficulty, in many cases, of determining the exact 
date at which an attack of enteric fever commences is, as 
is well known, very great. The earlier symptoms differ very 
much in severity in different cases, and, apart from this, 
differences in personal character and temperament lead some 
persons to continue about and at work for many days while 
suffering from symptoms which would have led others to seek 
medical advice. This source of fallacy must be constantly 
kept in view, but especially in examining cases in which an 
unusually prolonged period of incubation is reported. 

The histories of the epidemics which are given in the 
succeeding pages offer examples of the various modes of 
infection observed in enteric fever. 

In a minority of cases the person infected had been for 
varying periods in personal contact with a patient suffering 
from or convalescent from the disease. 

The other sources of infection include — 

Pollution of water-supply by the patient directly, or 
indirectly by soakage from cesspools or leaky drains. 

Pollution of milk by specifically polluted water used for 
adultei*ation, or for washing milk cans, and pollution of milk 
by air (?) . 

Infection conveyed by clothes — observed especially among 
washerwomen; pollution of well water by drainage from 
laundry. 

Air. 

Contamination of food by (?) air. 

'Incubation Period. 

The following table contains all the cases in which the 
duration of exposure to infection was for a known short period. 



56 



Enteric Fever. 



and those in whioh infection was detiyed from consamption of 
infected water^ milk, or food on a single occasion : — 















Interval before 


Report 




No. 




Source of infection. 




first symptom. 


X 




6 




Milk 


• •< 


6 


xxxii 




63 




Water 


• • 4 


8 to 10 


xxxii 




64 




>» 


• • a 


8 to 10 


xxxvi 




66 




Food 


• •1 


10 


xxxvi 




67 




»t 


• • 1 


10 


• • 

11 




2 




Water 


• • 1 


11* 


xxi 




. 19 




Milk 


• • 1 


12 






60 




? 


 •< 


18 to 14 


• • • 

XVlll 




26 




? 


. . « 


14 


xxxvi 




68 




Food 


• •< 


14 


, xxvi 




38 




? 


• • 


15 


• 

XI 




8 




Milk 


• • 


18 


xxi 




17 




»» 


• • 


19 to 21 


• 

XI 




7 




M 


• • 


22 



Gases in wliich the exposure to a source of infection 
commenced at an undetermined date but ceased at a known 
date are of value in determining the maximum period of 
incubation. Among the cases collected by the Committee in 
very few belonging to this class did the interval between the 
cessation of exposure and the onset of symptoms exceed 
fourteen days. The milk epidemic described in Report xiv 
ceased within seventeen days of the stoppage of the pre- 
sumed means of infection. In Gases 69 and 70 Dr. Murchison 
considered that the incubation period was twenty-one and 
twenty-two days respectively. In Gase 15 the history points 
to an incubation period of not less than twenty-three days ; 
in several cases the interval between cessation of exposure to 
infection was fourteen days exactly or approximately. 

Gases in which exposure to infection commenced at a 
known date, and continued thereafter for several days, are of 
value in showing the minimum period of incubation ; that is 
to say, they may afford evidence as to a period of incubation 
shorter than the average, if the average period of incuba- 
tion be taken as fourteen days. The following table gontains. 
the cases in which, if the evidence is accepted, the period of 
incubation must have been less than fourteen days; the facts 
do not of course show how much less the period was. 

* Many cases. 



Snteric Feven 57 

Inenbation period may bare 

Report Kg. Source of infection. been leu, bat cannot 

haye been more than 

xnr ... 26 ... Water ... 7 

XT ... 10 ... Fomites ... 9 

i ... 1 ... Water ... 10 

XV ... 11 ... Fomites ... 10 

XXX ... 47 ... Personal iotereourse ... 10 

XXX ... 4o ... $f ff ... Av 

XX ... XO ... ff ft ••• AA 

... DO •*. f) ft ... XX 

XXX ... 4.7 ... ty ft ••• ^^ 

XXX ... 50 ... 9, ff ... 12 

xxxiii ... 55 ... „ „ ... 12 

XXV ... — ... Water ... 11 to 13* 

xxi ... 21 .., Milk ... 13 

XXX ... 51 ... Personal intercourse ... 18 



That the period of incubation does really vary in different 
individuals who may have contracted the infection from the 
same source seems to be fairly certain. Shortening of the 
period to less than that usually observed has been noted by 
the Inspectors of the Local Government Board, but gener- 
ally in epidemics traced to milk. As an example may be 
quoted the following passage from Dr. Ballard's report on an 
outbreak of enteric fever at Armley.f He states that he 
found ^Hhat the largest consumers of the suspected milk 
were among the earliest, and the smallest consumers among 
the latest attacked.'^ Notes on this point were made in 
43 cases ; in 19 of these cases it was specially mentioned that 
the suspected milk was very freely used as an article of diet, 
commonly at supper, either cold or boiled. All but four of 
these individuals applied for medical aid in the course of the 
first fortnight of the outbreak. In 24 cases very little milk 
was taken, and of these 1 7 sought medical aid in the course 
of the third and fourth weeks of the outbreak, and only 3 in the 
first, and 5 in the second week. Remarks by Mr. W. H. Power 
to a similar effect will be found quoted in Keport xi at a later 
page ; and the same distinguished officer of the Board, in a 
report on a localised outbreak of enteric fever at Norwood, in 
the Uxbridge R. S. D. (dated June 6, 1882), writes with 
reference to the incubation of certain cases, " Shortening 

* 12 cases. 

t BeportM ofth€ Medical Officer of the Privy Council and Local Government 
Soardt ^ew Series, No. 2, *' Supplementary Report to the Local Government 
Board on some reeent inquiries under the Pablic Health Act, 1885/' London^ 
1874. [c 1066]. 



S8 Enteric Fever, 

of tlie incubation time may no doubt have occurred. It 
would be in accord with experience of certain milk outbreaks 
of enteric fever where consumers of large amounts of the 
implicated milk in a raw state have seemed to suffer fever 
within a very few days of their infective meal. And what is 
true of enteric fever conveyed by milk may be true also of 
enteric fever conveyed by water, for in both instances there 
is chance of infective matter of great potency getting applied 
directly and in abundance to the intestinal tract.'' Evidence 
which may be held to lend some support to this view is to 
be found in the limited epidemics described in Reports xxv 
and xxvii among others. 

The opinions above quoted as to the shortening of the 
period of incubation in some cases in which the infection is 
derived from milk appear to refer to exceptional events. In 
a few of the cases recorded in the following pages the period 
has been less than the average — in one case (6), if the evi- 
dence can be accepted, as short as five days; but in the 
majority the history is compatible with a period of fourteen 
days or longer. The following is a summary of the facts as 
to the period of incubation in the milk epidemics : 

Report No. 

X ... 6 ... Incubation period may have been 5 days, 

xzi ... 18 ... „ „ must „ 11 „ at least, 

xxi ... 19 ... „ „ was probably 12 „ 

xxi ... 21 ... ,^ „ may have been 13 „ 

xii ... 9 ... tf »» was probably 14 „ 

xxviii ... — ... The epidemic ceased a fortnight after the closure 

of the dairy, 

xxi ... 22 ... Incubation period may have been 15 days. 

XXI ... 2SO .«• yy If ft ft fy 

xiv ... — ... The epidemic had ceased 17 days after the pump- 
handle was chained, 
xi ... 8 ... Incubation period was probably 18 days, 
xxi ... 17 ... ,* ft must have been 19 ,, at least. 

xi .„ 7 ... ,. ,, was probably 22 „ 

xxi ... 20 ... Definite symptoms occurred 22 days after com- 
mencing to take the milk. 



Duration op Infectious Period. 

The number of cases which afford evidence as to the 
length of time during which a patient who is suffering or 
has suffered from enteric fever remains capable of communis 
eating the disease is small; it maj^ however^ be nsefol to 



Enteric Fever. 59 

direct attention to those whicli do supply evidence on this 
point. 

The incidents recorded in the Report by Dr. Parsons, here 
numbered xxx, leave little doubt that the disease was con- 
tracted from a patient in an early stage ; the young man who 
was the first sufferer presented the early symptoms of the 
disease when he first came into relation with the persons who 
nursed him, and the first cases occurred among them ten days 
later; there is, therefore, a strong presumption that these 
persons contracted the disease on the first day they came 
in contact with the young man, and while he was suffering 
from the early symptoms. In two other cases, however, 
in which the circumstances were very similar («ee Report xvii), 
the interval between the commencement of exposure and the 
onset of symptoms was considerably longer — at least three 
weeks. In the case mentioned in Report xxxi the wife of a 
man, who contracted the disease while at work, sickened a 
fortnight after her husband ; the inference appears to be per- 
missible that she took the disease from him while he was in a 
very early stage. 

In some of the reports relating to epidemics in which the 
infection was distributed by drinking-water there is presump- 
tive evidence that the infective material was derived from 
patients in an early stage. The small epidemic recorded in 
Report iv commenced within about seventeen days of the 
first occurrence of symptoms in the woman by whom the well 
is believed to have been specifically polluted. In the very 
similar incident contained in Report v the epidemic began 
within about fourteen days after the onset of symptoms in 
the first case. The occurrence related in the second para- 
graph of Report xiii also appears to afford evidence of 
contamination of well water by the excreta of a patient in an 
early stage; the value of the evidence, however, depends 
upon the degree of reliance which can be placed upon the 
disinfection of the soiled linen which is stated to have been 
practised after the first few days. In the well-known 
Caterham epidemic investigated by Dr. Thorne-Thorne 
(Report xxiii) the workman who infected the water-supply 
probably contracted the disease on December 25-6, and 
began to have diarrhcea on January 5 ; the first case in the 
epidemic occurred fourteen days later. The epidemic was 
mild, and it would not be safe to attach much importance to 
the precise dates at which cases came under treatment ; in 
fact, the cases appear to reach two maxima a week apart— on 



60 JEnteric Fever, 

Jannary 25 and February 1; these dajB were Saturdays^ 
and the great excess on them was probably due to their 
being half-holidays and the end of the working week. 
Broadly stated^ the facts of the epidemic are as follows^ and 
are not without value in the present connection : — The specie 
fie pollution was taking place during the two weeks ending 
January 11 and 18^ but no cases occurred during these 
weeks ; the specific pollution ceased on the following Monday, 
and the epidemic began on the preceding day. During this, 
the third week after the commencement of the contamination, 
56 cases were recognised; during the next week, 122 cases; 
and during the next^ the fifth after the commencement and 
the third after the cessation of the pollution, the cases fell to 
94 ; in the next week they fell to 57, and thereafter declined 
very rapidly. There is considerable probability, therefore, that 
a larger number of persons were infected during the second 
week of the patient's illness than at an earlier date. This 
epidemic may be compared with that which occurred in 1883 
at Hitchin, and was reported on by Mr. W. H. Power (Report 
xxix). In this instance the specific pollution occurred pro- 
bably on a single day only, and the epidemic reached its 
maximum during the third week thereafter, but cases con- 
tinued to occur during the next week. An epidemic at 
Ystalyfera (Report xxx), traced to the use of water from a 
particular cistern known to have been specifically contami- 
nated^ ceased, so far as regards its special incidence on houses 
supplied with water from this source, fourteen days after the 
closure of the cistern. In the Guildford epidemic contami- 
nated water was delivered on a known day, and on that day 
only, and the first symptoms in " a great proportion of cases " 
probably occurred eleven days later, and only in a minority 
of cases at a still later date (Report ii). 

Instances of infection derived in all probability from con- 
valescent patients are afforded by cases recorded in Reports 
XX and xxxiv. In the former a servant-maid entered a house 
and began to wait upon a patient who had been for twelve 
days convalescing from enteric fever ; eleven days later the 
maid began to have diarrhoea, and on her return home was 
the means of infecting three members of her own family. 
The fact that all the other inmates of the house in which the 
maid contracted the fever escaped, renders it highly probable 
that she derived her infection from the convalescent patient, 
with whom she was brought into very close contact. In thd 
ol^er instance a woman who took a convalescent child to her 



Enteric Fever. 61 

own house began to suffer from the disease twelve days later; 
in tMs case measures of disinfection had been taken^ but it 
is not known how far these were effectual as regards the 
clothes of the sufferer^ and it must be noted that the house 
from wbich the child was brought had been infected for 
seyeral months ; it is therefore possible that the woman may 
have contracted the disease during a visit to it. In Case 59 
a woman suffering from scarlet fever was admitted into a 
hospital which contained five patients convalescent from 
enteric fever^ and was waited upon by the same nurses. 
While convalescent from this fever, thirteen days after her 
admission into the hospital she again began to suffer from 
pyrexia, which turned out to be due to the onset of enteric 
fever. 

How long a source of water-supply once specifically pol- 
luted may retain the power of conveying infection must 
depend upon a great variety of circumstances, which cannot 
be discussed here ; in the case of a public water-supply, and 
a large body of water, it would seem that the removal of the 
source of contamination is followed after an interval of two, 
three, or at longest four weeks by a cessation of the epidemic, 
or at least of attacks directly contracted from the water. 
The case is probably different in small wells ; Reports xiii and 
xxii give the history of small epidemics which appear to be 
best explained by assuming that the infection remained for a 
prolonged period in some way associated with the well, but 
not necessarily in the water. As Mr. Spear has observed in 
a Report quoted below (xxxvi), 'Hhere is much ground for 
the belief that the typhoid contagion may lie dormant in the 
soil for prolonged periods, becoming again active during the 
heat of summer.*' A striking example of the retention of 
infection in clothing for a period of about two months is 
found in the instance of importation of the infection from 
Toronto to Oxfordshire given in Report xv. Another in- 
stance in which infection was presumably carried in clothes 
is contained in Report xxxiii. 

Conclusions. 

(1) The general conclusion to be drawn from all the facts is 
that the period of incubation in enteric fever varies within 
rather wide limits. The interval between exposure to infec- 
tion and the development of distinct symptoms is probably 
most often twelve to fourteen days ; it is not very infrequently 



62 Enteric Fever. 

nine or ten days^ occasionally eighty and possibly even less^ 
According to Dr. Murchison^ '' it may not exceed one or two 
days/^ but no case of the kind has been reported to the- 
Committee. In rare cases it is prolonged to fifteen^ eighteen, 
or even twenty-three days. Dr. Murchison thought it " very 
doubtful if the incubation period ever much exceeds three- 
weeks." 

(2) A patient suffering from enteric fever is capable of 
conveying the infection to others throughout the whole course 
of the disease^ from the date of the earliest symptoms of 
illness^ until convalescence has been established for at least a 
fortnight. 

(3) An epidemic due to milk contamination may be ex-*^ 
pected to cease at or about the end of the second week after 
the arrest of the contaminated supply ; but an epidemic due 
to contamination of a public water-supply may not come to 
an end until the fourth week after the source of specifia 
pollution has been removed. Where an epidemic can be 
traced to well water its duration may be very much more- 
prolonged^ and no general statement as to the probable date 
of its spontaneous termination can be made. 

(4) Infection can be conveyed by f omites, and retained ini 
them^ probably for two months at least. 



Enteric Fever. 6$ 



CASES 

Communicated by Sir Geobge Buchanan, M.D., F.B.8., late Medical 

Officer to the Local Government Board. 

i. Case 1. 

Report by Dr. B. Thobne-Thobnb on an Epidemic at Terling, 1868. 

Well water, — A certain well supplying a row of cottages was dry 
until November 26 ; on that day water was again found on it, and was 
used in one cottage (A) for drinking on ^November 26, but in the other 
cottages not until several days later, ** because it was turbid." The 
first case in the row {Case 1) occurred in Cottage A on December 6, ten 
days after the water was first used. 

ii. Case 2. 

Report by Dr. G. Buohanan on Enteric Fever at Gaildford, 1867. 

' Water-siwply. — Water believed on good evidence to have been the 
vehicle of infection was delivered on August 17, and on that day only. 
The first case (Case 2) came under medical observation on August 28, 
and a very large number subsequently (150 in first ten days of September). 
" The first symptoms in a great proportion of cases " probably occurred 
*' on or about August 28, or eleven days after the operation of the 
cause." " This limit was probably in certain cases really exceeded." 

iii. Case 3. 
Beport by Mr. Nbtten Badclibeb on Enteric Fever at Ingham, 1869. 

Well water, — The first case was a girl who was brought to Ingham 
on April 1 suffering from the fever. A certain well into which fever 
stools may have soaked was used by a man who was found tn be suffering' 
from fever on April 21. 

iv. 
Beport by Dr. Gwtnkb Habbibs on Enteric Fever at Burbage, 1871. 

Well water. — A woman sickened May 20 — 25, and had opportunity 
of using a privy near a certain well. Drinkers of this well water alone 
suffered. Fourteen cases occurred among them in the seven or eight 
days or so before June 12. 

V. 

Beport by Dr. B. Thobnb-Thobnb on Enteric Fever at Bishop's Stortford, 1873. 

Well water, — A bov who attended a day school in another part of 
the town was attacked with enteric fever while living in a cottage, one 
of a row of five, each with a separate drained closet, but a well in 
common. The soil-pipe of the closet in the house in which the boy 
lived leaked, and the well was seven feet away. The disease in this 
locality appeared to be distributed through the drinking-water. 
" Within fourteen days of the commencement of * the bov's ' attack " 
enteric fever bi*oke out in another cottage, and within three months 
all the cottages had been invaded. 



€4 Enteric Fever. 



VI. 

Reports by Dr. G. Bitchanan, Ecton, 1872, and Dr. B. Thobnb-Thobnb, 

Lewes, 1874. 

Ten days to a fortnight was the interval between exposure to pre- 
sumed cause and first manifestation of symptoms ; " but the causes are 
not 60 limited or so defined as to give any particular value to the cases 
as proving an incubative period." (G. B.) 

• • 

Vll. 

Report by Dr. Ballasd on Enteric Fever at Bourton, 1874. 

Biver wiUer, — On May 10 a case contracted at Oxford occurred at a 
mill a mile up stream, where the privy overhung the stream. The first 
medical attendance on cases of fever at Bourton (all having drunk the 
water) were made on June 10, 12, 13, 14, Id. Before September 10 one 
in twelve of the population had suffered. 

viii. Case 4. 
Report by Dr. G. Buchanan on Enteric Fever at Croydon, 1876. 

Pollution of domestic water-supply. — " At a school where foul air and 
other matters entering water-pipes is held to have been the mechanism 
of fever distribution, cases occurred before holidays and after holidays. 
The first case (Case 4) after holidays showed symptoms fourteen days 
after return of the pupil to the school." (G. B.) 

ix. Case 5. 

Report by Dr. Buchanan on Enteric Fever at Over Darwen. 

Pollrdion of urban water-supply. — Contamination of water-supply 
l)y leakage of pipes. First case occurred about fourteen days after. 

X. Case 6. 

Report by Mr. Nettbn Radoliffb and Mr. W. H. Poweb on Enteric Fever in 

Marylebone, 1873. 

JlftZft.-— A child {Case 6) spent July 19 with a family supplied by a 
dairy which was believed to have distributed milk containing the 
specific infection. On July 24 this child was attacked by the fever. 
If the child contracted the disease on July 19 the period oi incubation 
was only five days, a period shorter than in any other case. Of the 
family visited ten members were attacked between July 21 and August 1. 
** The £&cts concei*ning the differential distribution of ordinary and 
nursery milk in their relations to the distribution of fever could be 
explained if an incubative period of fourteen days more or less were 
granted." (G. B.) 

xi. Cases 7 amdS. 

Report by Mr. W. H. Powbb on Enteric Fever at Eagley, 1876. 

MiUc. — Mr. Power writes : — " Some facts of considerable pathological 
interest, as suggestive of inconstancy in the period of incubation of 
enteric fever, came under notice during the inquiry. It was observed 
that the interval elapsing between the last occasion upon which the milk 



EnteHe Fever. 65 

was taken and the beginning of illness was in several cases anusnally 
protraoted. In the following instances, causes of fever other tiian the 
milk could be almost absolutely excluded : — E. B., aged 14 {Case 7), one 
of a family not taking the particular milk, exceptionally partook of it 
on January 30 ; she was attacked on February 21. M. W., a^ed 15 
(Case 8), a member of another family not taking the milk, partook of it 
not later than February 2 (the date of arrest of this milk-supply in 
Eagley) ; she, attacked not earlier than February 20, became definitely 
ill with fever, February 25. Other and similar instances mi^ht be 
mentioned. On the other hand, there was found reason for believing 
that in many instances fever followed ver^ closely (in a few days) on the 
ii^ective dose of milk, though upon this head uie evidence was not 
completely demonstrative. It seems certain, however, that 'great 
milk drinkers ' were proportionately early sufferers in the outbreak." 
Both the above cases, however, occurred during an extensive epidemic, 
and it was therefore difficult to exclude other sources of contagion. 

xii. Case 9. 

Report by Dr. B. Thobnb-Thobnb on Enteric Fever at Brierley Lane, 1874. 

MiUc, — ^A young woman, not shown to have otherwise had oppor- 
tunity for infection, was in the habit of visiting a house where infected 
milk was used. Her last visit was paid a fortnight before she fell ill of 
the fever. 

• « • 

xui. 
Report by Dr. Ballabd on Enteric Fever at Moseley and Balsall Heath, 1878. 

Contamination of well water ; distribution by milk, — ^Between Novem- 
ber 24, 1872, and January 6, 1873, 96 cases occurred in 50 families, 
traced to miUc in 47 families. The milk was supplied by a milk-seller, 
next door to whom lived a man who had diarrhcBa on and after Novem- 
ber 3, rigors November 17, and died November 23. This man's privy 
soaked into the milk-seller's well. Evidence showed that the milk was 
contaminated after reaching the milk- seller's house. In the last few 
days of November, and in the week ending December 7, 20 fEimilies 
were attacked; in the week ending December 14, 11; in the week 
ending December 21, 12 ; in the week ending December 28, 3 ; and 3 in 
the foUowing week. The first cases occurred, therefore, a little more 
than three weeks after the commencement of the chance of specific 
pollution of the milk-seller's well. 

Contamination of well water by washings of foul linen, — A laundress, 
living in a row of cottases a mile away in the countrv, received a parcel 
of foul, not disinfected linen on December 9, 1872, from a case not yet 
under treatment. The common well of the row had opportunities of 
receiving washings of the infected clothes. The first case occurred in 
the row (not in the laundress's house) on January 4. The clothes sent 
to the laundress after December 11 were treated with disinfectants. 

xiv. 

Report by Dr. Ballabd on Enteric Fever at Armley, 1872. 

Contamination of well water ; d/istribution by miXk. — The milkman 
took to his bed with enteric fever, probably contracted in another 
town, on May 17. Opportunity existed for the milkman's well water 
to become infected ; this probably recurred during the week ending 

E 



66 Enteric Fever. 

June 8, owing to heavy rain which fell then. Two cases occnrred in 
one family, supplied by this milk-seller, on Jnne 20. Then an interval 
of ten days, and then a sudden outburst, namely, 12 new houses at- 
tacked between June 30 and July 6. In tiie week ending July 13, 11 
fresh houses; in the week ending July 20, 10 fresh houses ; and in the 
week ending July 27, 16 fresh houses were invaded. Thereafter a 
sudden diminution was noticeable in the number of houses attacked 
(in the week ending August 3 only 2). On July 10 the handle of the 
milkman's pump was chained up, and there was no suggestion of any 
other change in the circumstances to account for the sudden diminu- 
tion in the number of houses invaded which was noticed two weeks 
later. Specific pollution ceased July 10. Epidemic ceased week ending 
July 27. 

zv. Cases 10 to 12. 

Beport by Dr. Thobkb-Thobnb on Enteric Fever in an Oxfordshire Village. 

Fomites; evidence as to persistence of infection (instance recorded by 
Dr. Gilbert Child). — The wife of a man residing in Toronto died in 
September, 1873, of enteric fever. He subsequently left America, 
taking with him in several boxes bedding, clothes, &c., soiled by his 
wife during her illness. He arrived at his home in an Oxfordshire 
village on November 20, 1873 ; his mother and brother resided at this 
house. On November 29, 1873, the brother {Case 10) was seized with 
an attack of enteric fever which proved fatal. The mother {Case 11) 
sickened of the same disease on the following day. The only other case 
in the neighbourhood was a woman {Case 12), a relation of the man 
from Toronto, who had taken to her home some of the dirty things to 
wash. She was attacked December 5. 

xvi. 

Beport by Dr. Thobnb-Thobne on Enteric Fever at Clayton West, 187i. 

Fomites ; sewer air, — ^A laundress first received the first patient's 
foul linen " about middle of May." On June 16 a person in each of 
two houses having closest drain relations with the laundress's house 
fell ill of the fever. Fresh cases occurred almost day by day on the 
same local sewer system, until, in mid -August, 15 out of 23 cottages had 
had inmates attacked. " Drains and not water appear to have been 
the way of diffusing the fever infection in this case." 

xvii. 

Beport by Dr. Whitlbt (3rd Bep., M. O. P. C.) on Typhoid Fever at Kingston 

Deverell, 1860. 

Infection ofnwrses. — A man recently arrived home came under treat- 
ment for enteric fever on September 1, and was nursed by his mother, 
who came for that purpose from the other side of the village. His 
mother required medical treatment for enteric fever on September 23, 
and two women living next door, who had helped to nurse the man, 
" contracted " the fever September 25 and 30. 

A young man who sickened November 16 was removed to his 
mother's house November 18. He was also nursed by an aunt, who 
lived in an isolated house. Both mother and aunt were seized about 
December 10. A boy who lived in the aunt's house sickened January 5. 



Enteric Fever. 67 

xriii. Cases 13 cmd 14. 
Eeport by Dr. B. Thobne-Thobkb on Typhoid Fever at Torvey, 1876. 

Visit to infected village, — The first case in Torvey was a man (Ccue 
13) who drove to a neighbouring village with the doctor who was 
attending cases of enteric fever there. The man had no commnnication 
with any person, and took no food in this village, but " within about 
fourteen days " of his drive be was taken ill of enteric fever. 

Latmdress, — The second case in Turvey was a woman {Case 14) who 
during the latter part of the man's illness washed some foul linen in his 
cottage. " Within fourteen days " she was taken ill with well-marked 
typhoid. 

The third and last case was her son, who sickened within about a 
fortnight of his mother. 

xiz. Case 15. 

Report by Dr. Ballabd on Enteric Fever in Wakefield Prison, 1875 (from 
Official Report supplemented by Notes given privately). 

Sixty-nine persons among those within the precincts of the prison 
were attacked by a febrile disease, probably enteric fever. The cause 
of the fever existed within the prison (to what extent outside also could 
not be defined), and the means of distribution was probably drain air. 
Seven persons fell ill of the fever after their discharge from prison. 
One man (Case 15), admitted to the prison on November 12, 1874, was 
discharged from prison on January 10, 1875, and was then ** well." 
He shivered and vomited on February 2, and died on February 14. If, 
as was thought probable, he contracted the fever in prison, the incuba- 
tion period must have been prolonged — twenty-three days. 

XX. Case 16. 
Report by Dr. Ballabd on Enteric Fever at Cornbrooke, 1873. 

Infected by convalescent. — ^M. T. ( Case 16) went from home to service 
at Leamington on November 14. She had to wait on a patient who had 
fallen ill with enteric fever on October 16, and had begun to con- 
valesce on November 2. She alone of the Leamington famuy got fever. 
She sickened with diarrhoea on November 25, eleven days after enter- 
ing the house, and had rigors on December 2. She went home on 
December 8, and. was convalescent on December 30. Her sister S. 
sickened February 10, her mother February 12, and her father March 
12. Another sister, J., returned home on March 11, and sickened 
twenty days later (March 31). 

xxi. Cases 17 to 23. 

Dr. Ballabd's Report to the L. G. B. on an Unusual Prevalence of Enteric 
Fever at Ascot during a Period of 4^ Tears, dated July 10, 1878. 

Milk, — Previous to the middle of 1873, during a period of fortj 
years at least, no similar epidemic had occurred ; the principal medical 
practitioner stated that during his experience of forty years he had 
met with cases in his practice " now and then, but rarelv.*' P., a boy 
aged 10 {Case 17), went to London on or soon after July 2, 1873, and 
stayed two days. He returned to his father's house at Ascot from 



68 Enteric Fever. 

London, and was taken ill with enteric fever on July 23. There was 
an epidemic during the middle of 1873 in Marylebone, traced to the 
milk-Bupplj of a particular dairy. P. is known to have partaken of 
milk from this dairy (see above, Report x). 

MUh. — C, a boy aeed 9 (Case 18), went from his home in London to 
Ascot on Jnly 23. ae was taken ill with (enteric) fever on August 3, 
eleven days after ceasing to take the specifically polluted milk. 0. is 
known to have partaken of milk from the above-mentioned dairy. 

MUk.^A, housemaid {Ccue 19) at a house in Ascot, about half a 
mile from the house in which 0. resided, went to London on July 29, 
stopped the ni^ht at Fulham, visited a friend residing " within the 
Marylebone epidemic district, and returned to Ascot the next day. 
She was taken ill on August 10." (Twelve dajrs.) 

MiOc. — (hi January 18, 1875, five children went to a house at Ascot^ 
and at first used milk from cows kept for the supply of the family. 
On FebruBinr 23, this supply failing, milk was obtained from a dairy 
farm (" B. K. F."). The milk from this farm was " the chief agent in 
the distribution of the fever " among families in Ascot. On and after 
February 28 all the milk for the household was derived from this farm. 
The children returned to London on March 16, and on March 17 one of 
them (Case 20), who had been ailing for more than a week, was 
attacked with enteric fever. 

MUh. — Three children were taken to Ascot on April 10, 1877, 
From May 7 to 28 the children (and the children only) were sup- 
plied with milk from the farm « B. K. F." On May 20 one of the 
children (Case 21) was " attacked with enteric fever, and the other 
two (Cases 22 and 23) " were attacked" on May 22. Other persons in 
the house, and other families using milk from the same source as that 
given to tiie children before May 7, did not have the disease. 



Case 24,. 

Dr. Ballabd's Report to the L. G. B. on an Oatbreak of Enteric Fever at 
Toleame Head, New Quay, Cornwall, dated Febmary 24, 1880. 

Persistence of infection in well water, — ^The first case in the epidemic 
(of 1879) was a lady visitor who arrived January 11, and had fever when 
fixst seen by the medical man (Mr. Boyle) on Januarv 13 ; she passed 
through a typical attack. On February 22 the wife of the hotel keeper 
who had visited the house in which the visitor was ill during her illness 
was first seen by the medical man ; she had ** simple fever," probably 
ambulant enteric. On May 10 the Rev. Mr. E., his wife, four girls, aged 
respectively 6, 7, 11, and 13, and three women-servants, came to reside 
at a house opposite the hotel and having a w. c. draininfi^ into the same 
imperfectly ventilated cess-pit. The water-supply was from the hotel 
weU, close to which was a leakine drain. On Mav 26 or 27 (sixteen or 
seventeen days after coming to the house) Mrs. E. was taken seriously 
ill with rigors ; she was ill for three weeks, but had no diarrhoea. Mr. 
Boyle considered her disease to be unquestionably enteric fever, but 
she kept up in order to look after her child J. E., aeed 11, who on June 3 

itwenty-f our days after coming to the house) was found to be suffering 
rom enteric fever ; J. E. had £arrh(Ba, but no rose spots. On the same 
day, June 3, the child Margaret N., aged 6, was taken ill, and had an 
attack characterised both by diarrhoea and rose spots. Other cases 
of undoubted enteric fever subsequently occurred in the house. This 



Enteric Fever. 69 

f Amily oame to New Qnay from a Staffordshire Tillage where fever was 
not existent. 

At another house close to the hotel, draining into the same cess-pit, 
and in which the hotel water was used, cases of enteric fever occuired 
on July 11 and 14 and subsequently. Before these dates, viz. from 
June 30 to July 5, a Miss H. (Uase 24) visited at this house ; Miss H. 
from July 5 to Jul^ 16 stayed with a friend at Bristol, in whose house 
and immediate neighbourhood there had been no enteric fever. On 
July 16 she returned home to Esher, and on July 20, having been 
unwell for several days, she was firat seen by a medical man, and 
subsequently passed through an unquestionable attack of enteric fever, 
with a little delirium and an exceedingly full eruption. 

The infection in all these cases was most probably conveyed by the 
hotel water used for drinking. 

• • • 

XXUl. 

Dr. Thobnb-Thobne's Report to the L. G. B. on an Extensive Epidemic of 
Enteric Fever affecting especially Redhill .... and Caterham .... dated 
April 7, 1879. 

Direct infection of water-sv/pply, — The epidemic occurred among 
persons drinking the water of the Caterham Waterworks Company. 
During^ the latter part of 1878 and the banning of 1879 a new adit 
was being constructed from one of the old wells to a new bore which 
was then being sunk. Work was suspended on December 14 and 
resumed on December 29. J. K., one of the men working in the adit, 
began to suffer from diarrhoea and other symptoms of enteric fever on 
or about January 5 (he had probably contracted the disease during a 
visit to Croydon on December 2t>-6). 

The first case among the water consumers occurred on January 19, 
just fourteen days after J. K. had begun to be ill and to have diarrhoea ; 
three persons were attacked next day, and by the end of the week 56 
persons had been attacked. J. K. became too ill to work on January 

21, and did not work after January 20. The number of cases in the 
week ending February 1 was 122 ; in the week ending February 8, 94 ; 
in the week ending Februanr 15, 57 ; and in the week ending February 

22, 18. After F^ruary 20 the epidemic, as confined to drinkers of 
Caterham water, was at an end, though a few scattered cases occurred 
in the district later. 

The water was used in the Earls wood Asylum; the first case of 
enteric fever occurred there on January 28 ; on Februa^ 8 the use of 
the water was stopped, and no fresh case occurred after February 21. 

xxiv. 

Dr. Blaxall's Report to the L. G. B. on the Sanitary Condition of Certain 
Localities in the Blaby B. S. D. in connection with the Prevalences of 
Enteric Fever, dated July 21, 1881. 

Well wflrfer.— On July 10 an outbreak of enteric fever occurred 
amone the occupants of two isolated cottages about half a mile from 
the vmage of whetstone. On July 22 one of the sufferers, a married 
woman, died, and her husband with four children *' immediately left 
the house and went to stay with *' Mrs. C, living in Kenny's Yard at 
the entrance to the village. One of the children was at the time 
suffering from enteric fever, and a second child was attacked two or 



70 Enteric Fever. 

three days afterwards. The pump- well which supplied the drinking-- 
water was within six or seven feet of Mrs. O.'s front door, and it was in 
evidence that waste water was habitually emptied on the surface over 
this well, there to run or soaJc away. There was no doubt that the 
water, in which the linen soiled by these children was washed, went 
along with other waste water. About three weeks after the arrival of 
the mfected family at Mrs. O.'s an outbreak of fever occurred amongst 
the residents in Kenny's Yard, who all used Mrs. O.'s well ; thirt^n 
families out of nineteen were invaded between August 12 and 
September SO. 

zxv. Cases 25 to 37. 

Mr. W. H. Powbb's Report to the L. G. B. on a Localised Outbreak of Enteric 
Fever at Norwood, in the Uxbridge B. S. D., dated June 6, 1882. 

WeU water. — The outbreak was limited to the inhabitants of a 
portion of a terrace, and there was strong circumstantial evidence that 
the disease was communicated by drinking the water of a certain well. 
This well was exposed to the chance of specific pollution on and after 
November 27 ; there was " the usual difficulty in exactly fixing the date 
of attack," but Mr. Power by personal inquiry, case by case, ascertained 
that the early attacks occurred as follows : 

1 case (Case 25) doubtfully on or about December 4, seven days after 

commencement of specific pollution of water. 
12 cases (Cases 26 to 37) in the three days, December 8 to 10, eleven to 

thirteen davs after commencement of specific pollution of water. 
5 cases in the three days, December 11 to 13, fourteen to sixteen days 

after commencement of specific pollution of water. 

xxvi. Cases 38 to 40. 

Dr. Blaxall's Report to the L. G. B. on a Limited Outbreak of Enteric Fever 

at Sherborne, dated May 16, 1882. 

Short exposure; contamiination of waiter hy sewer air.— A young 
gentleman (Case 38), one of a family of eight residing in Sherborne, left 
home on January 19, 1882, for one night, returning on the following 
day, January 20. Fifteen days afterwards he complained of feeling 
unwell (February 4), and was first seen by a medical man on February 
11. " No other case occurred in this house or locality, and there can 
be little doubt the fever was contracted the night he slept from home.'^ 

There had been two other cases, however, in other parts of the town, 
commencing about December 9 and December 24 respectively. Evacua- 
tions or linen- washings from these two cases went into a sewer which 
was badly ventilated and liable to accumulations of filth. On Febru- 
ary 21, alter a long spell of dry weather ( Jauuai^ and February), this 
sewer was flushed by damming the sewer at various places, so that it 
filled with liquid, which was then rapidly discharged. By this operation 
foul air would be driven out at any w€»k traps or available openings. 
The water in the cisterns in one house (H. M.'s) was exposed to sewer 
air from this sewer, both from a closet pan and a sink. In another house 
(A.'s) the pipes conveying the drinking-water " were in direct relation 
with the closet pans. There was strong circumstantial evidence that 
a series of cases of enteric fever in these houses were due to drinking 
the water, and that its specific pollution occurred within the houses. 



Enteric Fever. 



71 



The first case (Case 39) in A/s house occurred on March 7 (fourteen 
days after the flushing of the sewer), the second on March 21 — fourteen 
days after the first case. The first case (Case 40) in H. M.'s house 
occurred on March 7 — fourteen days after the flushing. Subsequent 
cases occurred, two on March 14, and one on April 1, 5, and 7, respectively. 

xxvii. Cases 41 to 46. 

Dr. Blaxall's Report to the L. G. B. on an Oatbreak of Typhoid Fever in two 
Families within a Fortnight of their leaving a Lodging-houBe at We9to,n, &c,, 
dated June 21, 1883. 

Well water. — ^The family B. had lodgings at No. 4, X Buildings, from 
the end of June to the beginning of August. The tenancy began on 
June 27, but the members of the party arrived at different dates ; the 
latest arrival was Mr. H. B. The whole party, numbering six persons, 
left on August 8, and within fifteen days five of these persons were 
attacked with typhoid. One daughter, who left on July 29, escaped 
the disease. The infection was wiui a high degree of probability attri- 
buted to the drinking of water from a polluted well. The escape of 
Miss B., who left on July 29, renders it probable that the specific 
pollution, the source of which was not traced, occurred after that date. 
Mrs. B., who escaped the typhoid, lived in the lodgings from June 27 
to August 8. During this period she had facial erysipelas, and several 
of the young ladies suffered from diarrhoea. The whole party returned 
home to Bath on August 8. The sanitary arrangements of this house 
were good, and there were no fever cases in the city at or about that 
time. On August 12 Mr. and Mrs. B., and a Miss P. who had been 
with them at Weston, went to Malvern, and on the same day a son and 
daughter went to Bwlch Tremyn, near Abergavenny. The following 
table gives dates of moving and of attack : 



Case. 


Initials. 


Date of 
arrival at 


Date of 
departure 


Place and date of 
attack. 


No. of days 
after leaving 






Weston. 


from Weiton. 


Weston. 


_ 


Miss B. 


June 27 


July 29 


Escaped 


^^^ 




Mrs. B. 


>» 


Aug. 8 


>» 


— 


41 


Miss A. B. 


*» 




Bath, Aug. 17 


9 


42 


Miss P. 


July 3 




Malvern, Aug. 19 


11 


43 


Mr. B. 


July 7 




„ Aug. 23 


15 


44 


Miss E. B. 


July 28 




Bwlcb, Aug. 20 


12 


45 


Mr. H. B. 


Aug. 1 




„ Aug. 23 


15 



Another family, consisting of eleven people, went to Weston on 
July 20, and left August 10. Three of the children subse<iuently suf- 
fered from continued fever characterised by diarrhoea, and in all proba- 
bility typhoid. A little girl (Case 46) sickened August 23, and died 
December 2. Two little boys were ill on August 27, but eventually 
recovered without definite symptoms of typhoid. 




\ 







pecestt' 



I 



Enteric Fever. 78 

30. The table is given, as it appears to afford a good example of tiie 
reaction, so to speak, of a i)opnlation to specific pollution of its 
water-supply. The maximum is reached during the third week after 
the source of contamination is removed, and a rapid decline then takes 
place. 

XXX. Cases 47 to 52. 

Dr. H. F. Pabsokb' Report to the L. G. B. on the Prevalence of Enteric Fever 
in the Pontardawe B. S. D., &c., dated September 28, 1880. 

Infection of nivrses, — A young man, E. G., returned home from a dis- 
tance to Mawe Llanguicke on or about September 4, suffering from 
the early symptoms of enteric fever. He was visited and nuinsed bj 
relations and friends, of whom six took the disease, the dates of their 
commencing to be ill being two on September 14 (Cases 47 and 48), 
two on September 16 (Cases 49 and 50), one on September 17 (Ca^e 51), 
and one on September 26 (Case 52). 

Cistern water. — At YBtal3rfera a severe outbreak occurred amonjB^ 

Eeople using water from a particular cistern, which had become speci- 
cally polluted. The suspected cistern was closed on Sei>tember 26, 
and after October 10 the outbreak ceased so far as regards its especial 
incidence upon the houses supplied with water from this source. 



Dr. Page's Beport to the L. G. B. on at Outbreak of Enteric Fever in Beverley 

in 1884, dated Jannary 16, 1885. 

Infection in early stage, — Outbreak attributed to specific pollution 
of a certain water-supply. A railway labourer drank this water while 
at work only. He sickened on July 1, his wife a fortnight later. 

xxxii. Cases 53 and 54. 

Dr. Pabsokb' Beport to the L. G. B. on the Becent Epidemic of Enteric Fever 
in the Borough of Kidderminster, dated January 13, 1885. 

FoThded river waier, — Falling Sands consists of three cottages and a 
forge or rolling mill, situated on the river Stour, one mile below 
Kidderminster, in a low damp situation. At a time when enteric fever 
prevailed in Kidderminster the whole of the sewage of that town was, 
owing to an accident at the sewage works, pump^ into the Stour for 
three days, October 13, 14, and 15. On Octooer 23, ten days after com- 
mencement of assumed specific pollution of the Stour, two sisters 
(Cases 53, 54) living in one of the cottages at Falline Sands sickened 
with enteric fever, one at Shrewsbury,* the other at home ; the water- 
supply of the cottage was from a shallow dipping-place within a few 
yards of the river ; the water was evidently only soakage from the 
river, the level at the two places rising and fuHng together. The fever 
may therefore, in Dr. Parsons' opinion, have been contracted by 
drinking specifically polluted water from the dipping well, or by 
*' inhalation of fever germs in the spray of the sewage-polluted river 
water." The period of incubation of enteric fever is, he adds, " usually 

* She had left home on October 23, and began to feel ill shortly after her 
arrival at Shrewsbury. 



72 



Enteric Fever. 



XZVIU. 

Dr. F. W. Babbt'b Report io the L. Q. B. on the Qeneral Sanitary Condition of 
the Boroagh of Gateshead, &c., dated Jane 11, 1884. 

Infection in dairy, — Appendix B to this report contains a report bj 
Dr. Charles Green, Medical Officer of Health, on an outbreak of 
enteric fever in Gateshead in Febmary and March, 1883. ^ The infec- 
tion was clearly traced to the milk distributed from a particular dairjr. 
A child of the dairyman had enteric fever, and was nursed by its 
mother, who also milked the cows and washed the milk-vessels. The 
dfdry was closed on February 27. *' Oases continued to occur for about 
a fortnight, and then ceased." 



Mr. W. H. Power's Report to the L. G. B. on Epidemic Prevalence of Enteric 
Fever in the Hitchin R. S. D., dated May 16, 1883. 

PoUution ofpvblie water-gupply. — An epidemic of enteric fever was 
found to be in all probability due to contamination of the public water- 
supply. The water was from a chalk well, but the receiving tank at 
the pumping station was liable to pollution by the back-flow (through 
an overflow pipe) of the water of the Hiz (" hardly better than a ditch 
a few feet in width ") when this river was in flood. There were two 
outbreaks during the epidemic, one in mid-December, as to which 
nothing was discovered ; the other in mid- January. On December 30 
there was a heavy rainfall, and the water in the reservoir and delivered 
in the mains was turbid, owing to contamination by back-flow from 
the Hiz in flood. Mr. Power gives the following table, which also 
serves as a chart of the cases of enteric fever which subsequently oc- 
curred ; the dates are the dates of invasion : 



Week ending 


Week ending 


Week ending 


Week ending 


Week ending 


Jan. 6th. 


Jan. ISth. 


Jan. 80th. 


Jan S7th. 


Feb. 8id. 


1st Jan. 


8th Jan. 


14th Jan. 


22nd Jan. 


80th Jan. 


*> 


99 


9f 


23rd Jan. 


Ist Feb. 


Early Jan. 


9th Jan. 


16th Jan. 


25th Jan. 


99 


f* 


10th Jan. 


n 


26th Jan. 






** 


Mid-Jan. 


27th Jan. 






»f 


16th Jan. 


» 






11th Jan. 


tf 








12th Jan. 


»f 








» 


17th Jan. 
20th Jan. 







The defect which permitted the contamination was remedied on 
January 13. The cases in the week ending January 16 beloneed pro- 
bably to the outbreak which began in mid-December, but the later 
cases may be attributed to the occurrence of pollution on December 



Enteric Fever, 78 

30. The table is given, as it appears to afford a good example of the 
reaction, so to speak, of a ]>optilation to specific pollution of its 
water-supply. The maximum is reached during the third week after 
the source of contamination is removed, and a rapid decline then takes 
place. 

XXX. Cases 47 to 52. 

Dr. H. F. Pabsons' Report to the L. G. B. on the Prevalence of Enteric Fever 
in the Pontardawe K. S. D., &c., dated September 28, 1880. 

Infection ofmvrses, — ^A young man, E. G., returned home from a dis- 
tance to Mawe Llansuicke on or about September 4, suffering from 
the early symptoms of enteric fever. He was visited and nuraed hj 
relations and friends, of whom six took the disease, the dates of their 
commencing to be ill being two on September 14 (Cases 47 and 48^, 
two on September 16 {Cases 49 and 50), one on September 17 {Case 51), 
and one on September 26 {Case 52). 

Cistem water. — At Ystalyfera a severe outbreak occurred amonjs^ 
eople using water from a particular cistem, which had become speci- 
cally poUnted. The suspected cistem was closed on Septemb^ 26, 
and after October 10 the outbreak ceased so far as regards its especial 
incidence upon the houses supplied with water from this source. 



I 



Dr. PAex's Beport to the L. G. B. on at Outhreak of Enteric Fever in Beverley 

in 1884, dated Jannary 16, 1885. 

Infection in ea/rhf stage. — Outbreak attributed to specific pollution 
of a certain Water-supply. A railway labourer drank this water while 
at work only. He sickened on July 1, his wife a fortnight later. 

xxxii. Cases 53 and 54. 

Dr. Passokb' Beport to the L. G. B. on the Becent Epidemic of Enteric Fever 
in the Borongh of Kidderminster, dated January 13, 1885. 

PoUtded river water. — Falling Sands consists of three cottages and a 
forge or rolling mill, situated on the river Stour, one mile below 
Kidderminster, in a low damp situation. At a time when enteric fever 
prevailed in Kidderminster the whole of the sewaee of that town was, 
owing to an accident at the sewage works, pump^ into the Stour for 
three days, October 13, 14, and 15. On Octooer 23, ten days after com- 
mencement of assumed specific pollution of the Stour, two sisters 
{Cases 53, 54) living in one of the cottages at Falline Sands sickened 
with enteric fever, one at Shrewsbury,* the other at home ; the water- 
supply of the cottage was from a shallow dipping-place within a few 
yards of the river ; the water was evidently only soakage from the 
river, the level at the two places rising and feeling together. The fever 
may therefore, in Dr. Parsons' opinion, have been contracted by 
drinking specifically polluted water from the dipping well, or by 
" inhalation of fever germs in the spray of the sewage-polluted river 
water." The period of incubation of enteric fever is, he sulds, " usually 

* She had left home on October 28, and began to feel ill shortly after her 
arrival at Shrewsbury. 



72 



Enteric Fever. 



ZXYIU. 

Dr. F. W. Babbt's Report to the L. 0. B. on the General Sanitary Condition of 
the Borough of Gkteshead, Ac., dated June 11, 1884. 

Infeetian in dairy. — Appendix B to this report contains a report by 
Dr. Charles Green, Medical Officer of Heuth, on an outbreak of 
enteric fever in Gateshead in Febmary and March, 1883. ^ The infec- 
tion was clearly traced to the milk distributed from a particular daiiy. 
A cbild of the dairyman bad enteric fever, and was nursed by its 
mother, who also miiked the cows and washed the milk -vessels. The 
didry was closed on February 27. *' Oases continued to occur for about 
a fortnight, and then ceased." 

xxix. 

Mr. W. H. Powbb'b Report to the L. G. B. on Epidemic Prevalence of Enteric 
Fever in the Hitchin R. S. D., dated May 16, 1883. 

PoUution of public water-supply. — An epidemic of enteric fever was 
found to be in all probability due to contamination of the public water- 
supply. The water was from a chalk well, but the receiving tank at 
the pumping station was liable to pollution by the back -flow (through 
an overflow pipe) of the water of the Hiz (" hardly better than a ditch 
a few feet in width ") when this river was in flood. There were two 
outbreaks during the epidemic, one in mid-December, as to which 
nothing was discovered ; the other in mid- January. On December 30 
there was a heavy rainfall, and the water in the reservoir and delivered 
in the mains was turbid, owing to contamination by back -flow fr^m 
the Hiz in flood. Mr. Power gives the following table, which also 
serves as a chart of the cases of enteric fever which subsequently oc- 
curred ; the dates are the dates of invasion : 



Week endiug 


Week ending 


Week ending 


Week ending 


Week ending 


Jan. 6th. 


Jan. ISth. 


Jan. 90th. 


Jan S7th. 


Feb. Sid. 


1st Jan. 


8th Jan. 


14ith Jan. 


22nd Jan. 


30th Jan. 


»* 


>» 


»9 


23rd Jan. 


Ist Feb. 


Early Jan. 


9th Jan. 


15th Jan. 


26th Jan. 


» 


>» 


10th Jan. 


*> 


26th Jan. 






t» 


Mid-Jan. 


27th Jan. 


1 




>» 


16th Jan. 


>» 






11th Jan. 


M 








12th Jan. 


9> 








>» 


mh Jan. 

20th"jan. 
»» 







The defect which permitted the contamination was remedied on 
January 13. The cases in the week ending January 16 belonged pro- 
bably to the outbreak which began in mid-December, but the later 
cases may be attributed to the occurrence of pollution on December 



Enteric Fever. 78 

30. The table is given, as it appears to afford a good example of the 
reaction, so to speak, of a |>opiilation to specific collation of its 
water-supply. The maximnm is reached during the tnird week after 
the source of contamination is removed, and a rapid decline then takes 
place. 

XXX. Cases 47 to 52. 

Dr. H. F. Pabsonb' Report to the L. G. B. on the Prevalence of Enteric Fever 
in the Pontardawe B. S. D., &c., dated September 28, 1880. 

Infection of nn/rses, — ^A young man, E. G., returned home from a dis- 
tance to Mawe Llansuicke on or about September 4, suffering from 
the early symptoms of enteric fever. He was visited and nursed b^ 
relations and friends, of whom six took the disease, the dates of their 
commencing to be ill being two on September 14 (CcLsea 47 and 48), 
two on September 16 {Cases 49 and 50), one on September 17 (Case 51), 
and one on September 26 {Case 52). 

Cistern water, — At Ystalyfera a severe outbreak occurred amonjo^ 
people using water from a particular cistern, which had become speci- 
ncally polluted. The suspected cistern was closed on Sei>tembar 26, 
and after October 10 the outbreak ceased so far as reeards its especial 
incidence upon the houses supplied with water from this source. 



Dr. PAes's Report to the L. G. B. on at Outbreak of Enteric Fever in Beverley 

in X884, dated January 16, 1885. 

Infection in early stage, — Outbreak attributed to specific pollution 
of a certain water-supply. A railway labourer drank this water while 
at work only. He sickened on July 1, his wife a fortnight later. 

xxxii. Cases 53 and 54. 

Dr. Pabsoks' Report to the L. G. B. on the Recent Epidemic of Enteric Fever 
in the Borough of Kidderminster, dated January 13, 1885. 

PoUided river water. — Falling Sands consists of three cottages and a 
forge or rolling mill, situated on the river Stour, one mue below 
Kidderminster, in a low damp situation. At a time when enteric fever 
prevailed in Kidderminster the whole of the sewaee of that town was, 
owing to an accident at the sewage works, pump^ into the Stour for 
three days, October 13, 14, and 15. On October 23, ten days after com- 
mencement of assumed specific pollution of the Stour, two sisters 
(Cases 53, 54) living in one of the cottages at Falling Sands sickened 
with enteric fever, one at Shrewsbury,* the other at home ; the water- 
supply of the cottage was from a shallow dipping-place within a few 
jaHs of the river; the water was evidenUy on^ soakage from the 
river, the level at the two places rising and fsuling together. The fever 
may therefore, in Dr. Parsons' opinion, have been contracted by 
drinking specifically polluted water from the dipping well, or by 
** inhalation of fever germs in the spray of the sewage-polluted river 
water." The period of incubation of enteric fever is, he adds, " usually 

* She had left home on October 28, and began to feel ill shortly after her 
arrival at Shrewsbury. 



72 



Enteric Fever. 



XXTIU. 

Dr. F. W. Babbt's Report to the L. Q. B. on the General Sanitary Condition of 
the Borough of Ghiteshead, &c,, dated June 11, 1884. 

IrtfecHon in dairy, — Appendix B to this report contains a report by 
Dr. Charles Green, Medical Officer of Health, on an outbreak of 
enteric fever in Gateshead in February and March, 1883. The infec- 
tion was clearly traced to the milk distributed from a particular dairy. 
A child of the dairyman had enteric fever, and was nursed by its 
mother, who also milked the cows and washed the milk-vessels. The 
dairy was closed on February 27. *' Gases continued to occur for about 
a fortnight, and then ceased." 

xxiz. 

Mr. W. H. Powbe's Eteport to the L. G. B. on Epidemic Prevalence of Enteric 
Fever in the Hitchin B. S. D., dated May 16, 1883. 

Pollution of public water-supply. — An epidemic of enteric fever was 
found to be in all probability due to contamination of the public water- 
supply. The water was from a chalk well, but the receiving tank at 
the pumping station was liable to pollution by the back -flow (through 
an overflow pipe) of the water of tne Hiz {** hardly better than a ditch 
a few feet in width ") when this river was in flood. There were two 
outbreaks during the epidemic, one in mid-December, as to which 
nothing was discovered ; the other in mid- January. On December 30 
there was a heavy rainfall, and the water in the reservoir and delivered 
in the mains was turbid, owing to contamination by back-flow from 
the Hiz in flood. Mr. Power gives the following table, which also 
serves as a chart of the cases of enteric fever which subsequently oc- 
curred ; the dates are the dates of invasion : 



Week endiug 


Week ending 


Week ending 


Week ending 


Week ending 


Jan. 6th. 


Jan. 18th. 


Jan. 80th. 


Jan S7th. 


Feb. Srd. 


1st Jan. 


8th Jan. 


14>th Jan. 


22nd Jan. 


30th Jan. 


»» 


f* 


f> 


28rd Jan. 


Ist Feb. 


Early Jan. 


9th Jan. 


16bh Jan. 


25th Jan. 


»f 


** 


10th Jan. 


» 


26th Jan. 






»> 


Mid.Jan. 


27th Jan. 






>* 


16th Jan. 


>» 






11th Jan. 


f. 








12th Jan. 


>» 








1* 


17th Jan. 

20th Jan. 
>» 







The defect which permitted the contamination was remedied on 
January 13. The cases in the week ending January 16 belonged pro- 
bably to the outbreak which began in mid -December, but the later 
cases may be attributed to the occurrence of pollution on December 



Enteric Fever. 73 

30. The table is given, as it appears to afford a good example of tiie 
reaction, so to speak, of a iK>piilation to specific pollution of its 
water-supply. The maximum is reached during the third week after 
the source of contamination is removed, and a rapid decline then takes 
place. 

XXX. Cases 47 to 52. 

Dr. H. F. Pabsons' Beport to the L. G. B. on the Prevalence of Enteric Fever 
in the Pontardawe B. S. D., &c., dated September 28, 1880. 

Infection of mtraes, — ^A young man, E. G., returned home from a dis- 
tance to Mawe Llanguicke on or about September 4, suffering from 
the early symptoms of enteric fever. He was visited and nursed b^ 
relations and friends, of whom six took the disease, the dates of their 
commencing to be ill being two on September 14 {Cases 47 and 48^, 
two on September 16 (Cases 49 and 50), one on September 17 {Case 51), 
and one on September 26 {Case 52). 

Cistern water. — At Ystalyfera a severe outbreak occurred among 
people using water from a particular cistern, which had become speci- 
fically polluted. The suspected cistern was closed on Sejjtembar 26, 
and after October 10 the outbreak ceased so far as regards its especial 
incidence upon the houses supplied with water from this source. 



Dr. Paob's Beport to the L. G. B. on at Outbreak of Enteric Fever in Beverley 

in 1884, dated January 16, 1885. 

Infection in early stage, — Outbreak attributed to specific pollution 
of a certain water-supply. A railway labourer drank this water while 
at work only. He sickened on July 1, his wife a fortnight later. 

xxxii. Cases 53 and 54. 

Dr. Passokb' Beport to the L. G. B. on the Becent Epidemic of Enteric Fever 
in the Borough of Kidderminster, dated January 13, 1885. 

Polluted river water. — Falling Sands consists of three cottages and a 
foree or rolling mill, situated on the river Stour, one mile below 
Kidderminster, in a low damp situation. At a time when enteric fever 
prevailed in Kidderminster the whole of the sewaee of that town was, 
owing to an accident at the sewage works, pump^ into the Stour for 
three days, October 13, 14, and 15. On Octooer 23, ten days after com- 
mencement of assumed specific pollution of the Stour, two sisters 
{Cases 53, 54) living in one of the cottages at Falling Saiids sickened 
with enteric fever, one at Shrewsbury,* the other at home ; the water- 
supply of the cottage was from a shallow dipping-place within a few 
yards of the river ; the water was evidently only soakage from the 
river, the level at the two places rising and fsuling together. The fever 
may therefore, in Dr. Parsons' opinion, have been contracted by 
drinking specifically polluted water from the dipping well, or by 
** inhalation of fever germs in the spray of the sewage-polluted river 
water." The period of incubation of enteric fever is, he adds, " usually 

* She had left home on October 23, and began to feel ill shortly after her 
arrival at Shrewsbury. 



72 



Enteric Fever. 



XZYIU. 

Dr. F. W. Babbt'b Report to the L. Q. B. on the General Sanitary Condition of 
the Borongh of Gkteshead, &c., dated June 11« 1884. 

Infection in dairy, — Appendix B to this report contains a report by 
Dr. Oharles Green, Medical Officer of Heuth, on an outbreak of 
enteric fever in Gateshead in February and March, 1883. The infec- 
tion was clearly traced to the milk distributed from a particular dairy. 
A child of the daiiyman had enteric fever, and was nursed by its 
mother, who also milked the cows and washed the milk-vessels. The 
didry was closed on February 27. *' Gases continued to occur for about 
a fortnight, and then ceased." 

xxix. 

Mr. W. H. Powbb's Report to the L. G. B. on Epidemic Prevalence of Enteric 
Fever in the Hitchin R. S. D., dated May 16, 1883. 

Pollution of public VDater-supply. — An epidemic of enteric fever was 
found to be in all probability due to contamination of the public water- 
supply. The water was from a chalk well, but the receiving tank at 
the pumping station was liable to pollution by the back -flow (through 
an overilow pipe) of the water of the Hiz (" hardly better than a ditch 
a few feet in width ") when this river was in flood. There were two 
outbreaks during the epidemic, one in mid-December, as to which 
nothing was discovered ; the other in mid- January. On December 30 
there was a heavy rainfall, and the water in the reservoir and delivered 
in the mains was turbid, owing to contamination by back-flow fr\>m 
the Hiz in flood. Mr. Power gives the following table, which also 
serves as a chart of the cases of enteric fever which subsequently oc- 
curred ; the dates are tiie dates of invasion : 



Week endiug 


Week ending 


Week ending 


Week ending 


Week ending 


Jan. 6th. 


Jan. 18th. 


Jan. 90th. 


Jan S7th. 


Feb. 8rd. 


1st Jan. 


8fch Jan. 


14th Jan. 


22nd Jan. 


30th Jan. 


» 


»f 


*> 


28rd Jan. 


1st Feh. 


Early Jan. 


9th Jan. 


15th Jan. 


26th Jan. 


M 


*» 


10th Jan. 


»f 


26th Jan. 






»> 


Mid-Jan. 


27th Jan. 






9* 


16th Jan. 


9» 






11th Jan. 


»* 








12th Jan. 


M 








»* 


I7th'jan. 

20th Jan. 
»» 







The defect which permitted the contamination was remedied on 
January 13. The cases in the week ending January 16 belonged pro- 
bably to the outbreak which began in mid-December, but the later 
cases may be attributed to the occurrence of pollution on December 



Enteric Fever, 78 

30. The table is given, as it appears to afford a good example of the 
reaction, so to speak, of a i>optilation to specific pollution of its 
water-supply. The maximum is reached during the tnird week after 
the source of contamination is remoyed, and a rapid decline then takes 
place. 

XXX. Cases 47 to 52. 

Dr. H. F. Pabsons' Report to the L. G. B. on the Prevalence of Enteric Feyer 
in t^e Pontardawe B. S. D., &c., dated September 28, 1880. 

Infection ofmvrses, — A young man, E. G., returned home from a dis- 
tance to Mawe Llanguicke on or about September 4, suffering from 
the early symptoms of enteric fever. He was visited and nursed hj 
relations and friends, of whom six took the disease, the dates of their 
commencing to be ill being two on September 14 {Cases 47 and 48), 
two on September 16 (Cases 49 and 50), one on September 17 {Case 51), 
and one on September 26 {Case 52). 

Cistern water, — At Ystalyfera a severe outbreak occurred amon^ 
people using water from a particular cistern, which had become speci- 
ncally polluted. The suspected cistern was closed on Sei|tember 26, 
and after October 10 the outbreak ceased so far as regards its especial 
incidence upon the houses supplied with water from this source. 



Dr. Page's Beport to the L. G. B. on at Outbreak of Enteric Fever in Beverley 

in 1884, dated January 16, 1885. 

Infection in early stage, — Outbreak attributed to specific pollution 
of a certain water-supply. A railway labourer drank this water while 
at work only. He sickened on July 1, his wife a fortnight later. 

xxxii. Cases 53 and 54. 

Dr. Pabsoks' Beport to the L. G. B. on the Becent Epidemic of Enteric Feyer 
in the Borongh of Kidderminster, dated January 13, 1885. 

FoUvied river water, — Falling Sands consists of three cottages and a 
foree or rolling mill, situated on the river Stour, one mue below 
Kidderminster, in a low damp situation. At a time when enteric fever 
prevailed in Kidderminster the whole of the sewage of that town was, 
owing to an accident at the sewage works, pump^ into the Stour for 
three days, October 13, 14, and 15. On Octooer 23, ten days after com- 
mencement of assumed specific pollution of the Stour, two sisters 
{Cases 53, 54) living in one of the cottages at Falline Sands sickened 
with enteric fever, one at Shrewsbury,* the other at home ; the water- 
supply of the cottage was from a shallow dipping-place within a few 
yards of the river ; the water was evidently on^ soakage from the 
river, the level at the two places rising and filling together. The fever 
may therefore, in Dr. Parsons' opinion, have been contracted by 
drinking specifically polluted water from the dipping well, or by 
'* inhalation of fever germs in the spray of the sewage-polluted river 
water." The period of incubation of enteric fever is, he adds, " usually 

* She had left home on October 23, and began to feel ill shortly after her 
arrival at Shrewsbury. 



82 Influenza. 



CASES. 

Cases 1 to 62. 
Obmmnnicated by Dr. H. Howard Mtxbpht. 

Notes on epidemic at Tunchenham, Janua/ry and Fehrua/ry, 1890. 
Dr. Murphy assumes that influenza appeared in London in December, 
and was prevalent by Ohiistmas in an epidemic form. Most of the 
families bad one or more members going to London daily on business. 
During the last week in December and the first week in January few 
people were affected, and it was " possible to decide without doubt the 
source and time of infection." 

Mr. Q., who went to London daily, was ill with influenza on 
December 25 ; on December 31 Mrs. A. (Case 1) called and had a few 
minutes' conversation with Mr. Q. She was taken ill on January 3, 1890 
(three days). The next case (Case 2) in Mrs. A.'s house occurred on 
January 6 (three days) ; three other cases occurred on January 8 (five 
or two days) ; other cases occurred on January 10 and 11. No second 
case occurred in Mr. Q.'s house until January 15. 

On January 3 Miss M. (Case 3) had a few minutes' conversation at 
a party with a young lady who said she was suffering from influenza. 
M!iss M. had a characteristic attack on Januaiy 6 (less than three days). 

Mr. G., who went to London daily, was taken ill January 5. Mrs. N, 
(Case 4) visited him for a short time on January 5, and was taken ill 
January 10 (five days). 

^ Miss R. (Case 5) saw a friend ill with influenza on January 12. 
She was attacked on January 15 (three days), and her sister (Case 6) 
(who had not been with her on January 12) was taken on January 18 
(three days). 

Mrs. H. and family lived a very retired life. On January 9 the 
governess took the four children to a P^'^y* also attended by some other 
children recently ill with influenza. The governess and one child 
(Cases 7 and 8) were ill on January 13 (four days), two other children 
(Cases 9 and 10) on January 14th (five days), and the fourUi child on 
January 15. 

On January 17 persons who had recently had influenza called on 
Mrs. B. (Case 11); she was taken ill on January 21, and Miss B. 
(Case 12), who had not seen the strangers on January 25. 

Mrs. B. G., living in the north of London, went to Twickenham on a 
visit on December 17. She was taken ill with influenza on December 19, 
the first case in the neighbourhood known to Dr. Murphy. Mr. 0. G. 
(Case 13) was taken ill on December 23 (four days). Other cases 
followed in this household on December 26, 31, and January 9. 

0. J., a boy, stayed a few days in London with his father, who had 
had influenza on December 22. 0. J. returned home to Twickenham 
ill on January 4. Other cases followed in the family, viz. the baby 
(Case 14) on January 8 (four days), Mrs. J. and a boy on January 12. 
Other cases followed on January 18, 22, and 25. 

A boy, K., who had been staying for a few days with friends in 
London who had had influenza, returned to Twickenham on Decem- 
ber 31, and was taken ill. Four of his brothers and sisters were taken 
ill on January 2 (Cases 15, 16, 17, 18) (two days), Mr. K. (Case 19) on 



Influenza. 83 

January 3 (three days), a child and two servants on January 5, and 
Mrs. K. on January 7. 

Mr. H., who went to London daily, was taken ill on December 28 ; 
Mrs. H. and a servant (Cases 20 and 21) on January 2 (not more than 
five days). 

Mr. O., who lived in a business house in London where many had 
been ill with influenza, was taken ill December 27, and returned home 
December 28. He went back to London next day. His sister {Gaae 22) 
was taken January 1 (not more than four nor less than three days). 
Other cases occurred in the same household on January 9, 13, 29, 30. 

Mr. B., who went to London daily, came home ill on January 2. 
On January 9 Mrs. B. and her parents (Caaea 23, 24, 25) were attacked 
^seven days after B.) ; a servant on January 8. 

Mr. C, who went to London daily, was ill on January 4; Mrs. G. 
{Case 26) on January 8 (four days). 

Mr. A., who went to London daily, was ill on December 21, the 
baby (Case 27) on December 24 (three days), a servant on January 4, 
.and another child on January 25. 

Mr. G., who went to London daily, was taken ill on December 29, 
Mrs. G. (Case 28) on January 1 (three days), Miss G., January 5 (four 
days after her mother), Miss M. G., January 18. 

Mr. L., who went to London daily, was taken ill on January 6, a 
servant (Case 29) on January 9 (three days), Mrs. L. on January 16, 
iiwo children on January 23, and one on January 27. 

Mrs. L.'s governess was attacked on January 9, after visiting 
friends in London who had been ill. A child (Case 30) was attacked 
-on January 12 (three days), Mrs. L. and another child on January 18, 
Mr. L. on January 19, and another child, who had been kept as 
separate as possible, on January 29. 

Infection conveyed by patient seven days after attack. — Mr. L., who 
lives in London, was taken ill January 11 ; he went to stay with relations 
^t Twickenham on January 18. One of them (Case 31) was attacked 
on January 21 (three days), and another (Case 32) on January 23 (not 
more than five days). 

Mr. P. went to work daily in a neighbouring town. He was taken 
ill on January 8, his child (Case 33) on January 11 (three days), his 
wife on January 14 (three days after child), baby on January 25. 

Mrs. W.'s serving maid (Case 34) went to see her mother ill with 
influenza in a neighbouring town on January 5, she was taken ill on 
January 9 (four days), was sent home on January 11, returned to her 
place January 15. Mr. W. (Case 35) was taken ill January 18, baby 
January 28, Mrs. W. February 1. 

Mr. H. went to London daily, was taken ill on January 14, the baby 
{Case 36) on January 19 (five days), child on January 22, servant 
Januai*y 24, another child and another servant on January 25. 

Miss D. B. while awav from home on January 14 was tak^ ill, and 
returned home January l5. Mrs. B. (Case 37) was taken ill January 19. 
Both kept in their bedrooms for ten days, till January 29. A servant 
{Case 38) sickened February 3, and the charwoman (Case 39) who waited 
on her February 6. 

Miss X. B., having influenza, went on January 18 to stay with 
Mrs. S. (Case 40), who had influenza on January 24 (not more than 
•six days). 

Mr. Z., residing in a business house in a neighbouring suburb, was 



84 Influenza. 

taken ill on December 30, and went to his home at Twickenham that 
evening. Mrs. Z. {Case 41) was taken ill January 3 (fonr days), a 
child on Jannary 10, and another child on Jannary 25 (from a different 
sonrce of infection, according to the mother). 

The disease appeared in the house of business mentioned in the 
above paragraph under the following circumstances : the health of all 
in the house was good when on December 21 Mr. Y . went to visit some 
friends in London ; he returned on December 23, and was taken ill on 
December 24. The next case {Case 43) occurred in the house three 
days later on December 27, and, three days later again, six cases {Cases 
45, 46, 47, 48, 49, 50) occurred on December 30. 

Mrs. W.'s child, who goes to school, was taken ill on December 28, 
and a younger child {Case 51) who was kept at home, on December 31 
(three daj^, 

Mrs. D,, who may have been exposed to infection while shopping, 
was taken ill on January 2, her daughter {Case 52) on January 5 
(three days), and Mr. D. {Case 53) on January 6 (four days). 

Second attack after forty-three years, — Mrs. L. {Case 54), a^ed 80, had 
influenza badly in 1847. On January 6, 1890, she had similar but 
much milder symptoms. Miss L. (Case 55) was attacked January 10 
(four days), a servant on January 17. 

Mrs. B., who may have been exposed while at work, was taken ill 
January 9, and her child {Case 56) January 11. 

Mrs. Fa., who thought " she g^t it shopping," was taken ill January 
10, a child {Case 57) on January 14 (four days), another on January 27. 

Mrs. Fb. was taken ill January 22, a child (Case 58) on Januaiy 26 
(4 days), another {Case 59) on January 27, and a third {Case 60) on 
January 28. 

Mrs. M.'s child was taken ill January 23, and the baby {Case 61), 
who was kept at home, on January 28 (five days). 

The writer considers — 

(a) That the usual period of incubation is probably about seventy- 
two hours. 

(b) That the period of infectiousness begins with the initial sym* 
ptoms, and lasts at least eight days. 

(c) That the contagium is probably conveyed in the breath, since 
there is no rash or desquamation. 

{d) That the contagium does not travel far, since in households in 
which the sick kept their rooms no fresh cases occurred until they got 
about the house again. 

(e) That isolation of the sick and the use of disinfectants (carbolic 
baths, sheets, spray, <&c.) were efifectual in preventing its spread in 
every case in which he resorted to these means. 

(/) That no evidence could be obtained pointing to infection by 
clothes, letters, furniture, milk, or water. 

Cases 62 to 67. 
Commniiicated by Dr. J. H. Wilson, Kenninghall, Thetford. 

The only three houses in which Dr. Wilson knew influenza to be in 
his neighbourhood on January 13, 1890, were those in which the head 
of the nimily had just returned from London, (a) E. S. G. (Case 62) 
spent three days in London while in good health, and returned on 
Saturday evening, January 4. The next evening, January 5, he began 



Infltienxa. 85 

to be ill with influenza. On January 7, in the mornine (2i days), 
one of his boys (Case 68) sickened, and by January 8 in tiie morning 
two more boys (Cases 64, 65) were ill. On January 10 two more chil- 
dren were taken ill suddenly ; on January 11 one more ; on January 12 
another; two others — nine in all — were affected before January 13. 

(b) In the second household the head of the family (Case 66) exhibited 
initial symptoms of influenza twenty-four hours after his return from 
London, and four other members of the family suffered soon after. 

(c) In the third household (different parish) the father (Case 67) also 
exhibited the initial symptoms twenty-four hours after his return from 
London. 

Case 68. 
Communicated by Dr. Edwasd Casey, Windsor. 

Irrfection conveyed dwring initial symptoms. — C. (Case 68), residing in 
a sequestered country parish, was visited on January 1st bjr B., who 
dined with him. B. had come from a house at a distance in which 
influenza was present, and was already showing the early symptoms of 
what proved to be a sharp attack. On January 4 G. had some sore 
throat, on January 5 felt very tired, on January 6 felt ** bad," and on 
January 7 suffered chills, headache, &c., followed by an ordinary 
attack (sore throat three days, and chills six days after B.'s visit). No 
other case occurred in the village until a fortnight later. 

Case 69. 

Communicated by Dr. C. J. Cullikowobth, London. 

A young lady (Case 69) came to London to stay with friends at 
Christmas. She met a brother living in London on January 3 (and 
probably on previous occasions), and not again until January 7. On 
January 6 this brother had well-marked symptoms of epidemic in- 
fluenza, but the next day he was well enough to meet his sister and 
accompany her to Kensing^n Museum. They were together from 6.30 
to 9.30 p.m., and on parting kissed. A.bout 5 p.m. on January 8 the 
lister began to feel chilly and ill, and January 9 she had undoubted 
influenza. The only other known communication with previous cases 
was — (1) At noon on January 6 she received, opened, and read a letter 
from a lady who had recently had influenza. (2) At 11 a.m. on 
January 7 she went to a house in which were at that time several cases 
of influenza. 

Case 70. 

Communicated by Dr. Jab. E. Sinolaib, Storey's Gate, London. 

The first cases of the general outbreak were observed by Dr. Sin- 
clair in his practice on and after December 13, but his child's nurse 
(Case 70) was taken ill with well-marked typical influenza on December 
3; she was convalescent on the fifth day, but had a relapse on 
December 20. The child slept in the same room, except from Decem- 
ber 3 to December 8 ; it did not develop the disease. The nurse had 
had no communication by letter with any country affected with the 
epidemic ; she knew no one ailing in London ; except to church, she was 
never out of the house except with the child ; but on November 30 
{three days before the initial symptoms in the nurse) a lady called at 



86 Infiuenza. 

Dr. Sinclair's house and went into the nursery. This lady " had just 
come from Paris, leaving her household there ill with 'la grippe/ 
This lady returned home, and was ill herself in Paris of the epidemic 
on December 24th." Dr. Sinclair considers that the nurse must have 
acquired the disease either from animals out walking, or from this 
third party who had not then had the disease. 



Caaet 71 to 73. 
Commnnicated by Dr. William Sqttibx. 

A girl aged 17, residing at South Kensington, was seized suddenly 
on December 14, 1889. She was in bed for two days, and on Decem- 
ber 17 and 18, during which days she was still confined to her room, 
her brother, M., aged 14 {Case 71), was much with her. He was seized 
suddenly on December 19, two days after coming into intimate relations 
with his sister. 

A lady aged 22, residing at Ealing, was seized suddenly on Decem* 
ber 29, lo89, the day after going to London. This was the first case in 
the house. On December 27 another lady, A. (Case 72), arrived in the 
house on a visit from the north of London. A. was attacked suddenly 
on December 31. The incubation period may have been two or four 
days. Her sister, who was much with her on January 1 and 2, was 
taken ill on the night of January 2. 

A lad {Case 73), aged 15, came to London in good health on January 
4, 1890, from a house in which there had been no cases of influenza. 
He was seized with influenza on the following day, Januaiy 5. 

Case 74. 
Commnnicated by Dr. Dawson Williaks. 

On a Thursday and Friday some amateur theatricals were given in 
an isolated country village in which no cases of influenza had previously 
occurred. On the Sunday and Monday numerous cases occurred in the 
village* especially among children who had attended the theatricals* 
On the previous Monday a gentleman (Case 74) su£fering from influenza 
had arrived from London, stayed at a house just outside the village, 
and attended the theatricals. On the Friday nis hostess, who acted as 
prompter, felt ill while engaged in that capacity, and had a well-marked 
attack on the following day. 

Case 75. 

Commnnicated by Mr. W. J. TowNSBin) Babkbb, Chnrchingford, near 

Honiton.* . 

Mr. X. {Case 75), aged 47, subject to bronchitis and laryngitis, went 
to Paris on December 18, 1889, stayed that night in an hotel where 
there were several cases of ''la grippe/' and returned home on Decem- 
ber 19. He was taken ill on December 22 (three davs) and had an 
attack of influenza of catarrhal type. This was the nrst case in the 
neighbourhood, and the six cases which alone followed had all been in 

* Reported also in Brit. Med Joum,, 1890, i, p. 202. 



Influenza. 87 

relation with Mr. X., viz. a daughter taken ill on January 2, a son on 
January 5> two daughters on January 7, a daughter on January 10, 
and Dr. Townsend JBarker on January 11. 

Epidemics on Shipboard, 

An outbreak of influenza on board the industrial training ship 
'* Mount Edgcumbe " (Saltash, Cornwall).* The first case occurred on 
January 31st, 1890. On February 2 there were six fresh outbreaks ; 
on February 3, eight fresh cases ; and on February 4, 5, and 6, on each 
day sixteen fresh cases; thereafter a smaller number, the last case 
being^on February 11. 

<*Serapis'' (troop-ship), quoted by Dr. Parsons. On passage to 
Bombay. The first case was an oficer who visited some friends at 
Malta (who had been suffering from the disease) on December 26, 
1889, he being attacked on December 31. The next case was on 
January 1, when near Suez. Ship left Portsmouth on December 18. 

At the meeting of the Academic de Medicine on February 4, 1890,t 
Dr. Proust reported the following instance communicated to him by 
Dr. d'Hoste of the steamship " Samt Germain." This boat left Saint- 
Nazaire on December 2, it was at Pauillac December 3 and 4, and on 
December 5 it called at Santander, where it embarked a passenger 
coming from Madrid ; the health of the ship was excellent, but on the 
day after his embarkation this passenger was seized with influenza. 
Four days later (December 10) Dr. d'Hoste was seized with influenza, 
then two days after him an attendant, and then the epidemic became 
general, affecting altogether 154 passengers out of 436, and 47 sailors. 

M. Danguy des Deserts, J m^cin-m^jor de la Bretagne, states that 
the training ship '* Bretagne " moored in the roads at Brest had a com- 
plement of 850 men, of whom 244 were attacked by influenza during the 
second half of December, 1889. On December 11 an officer received 
from Paris, where influenza was then prevalent, two large trunks 
containing boxes packed in wood shaving^ ; he unpacked them himself, 
and three days afterwards he was attacked with influenza ; on the next 
day and the day after his wife and three servants were attacked. On 
December 14 this officer went on board the " Bretagne " and remained 
twenty -four hours ; the second case on board the vessel was an adjutant 
attacked on December 16, and the epidemic broke out on December 17, 
from 20 to 45 men sickening by day. In every case in which an officer 
was allowed to go ashore to be treated at home the disease subse- 
quently broke out in his family. Up to the end of December the number 
of cases in the town of Brest had been small, and up to the same period 
no cases had occurred on board two other training ships, the '* Borda 
and the " Austerlitz," which were moored alongside the ^'Bretagne. 

* Dr. George Preston, Srit. Med. Joum., 1890, i, p. 477. 

t BulleHn, xxiii, p. 170. 

X Semaine MSdieale, 1890, p. 5. 






MEASLES. 

THE late Dr. Murchison {Transactions, vol. xi, p. 241) ex- 
pressed the opinion that the incubation period of measles^ 
although subject to variations^ is quite as definite as that of 
smallpox. The discrepancy in the statements made in dif- 
ferent works was, he maintained, due in a large measure to 
difEerences in the mode of calculating the period of incubation, 
which was frequently taken to end only at the time when the 
rash appeared, so that the stage of primary fever, which lasts 
three or four days, had been included in the period of incuba- 
tion. Making allowance for this, he concluded that ^^ the in- 
cubation period of measles is usually about ten or eleven days. 
It is worth noting, however, '^ he continued, ^^ that, just as in 
the case of smallpox, when the poison is introduced by inocu- 
lation, the incubation period is shorter, or only seven days.* 
.... The best observations on the incubation period of measles 
with which I am acquainted are those made by Panum in the 
epidemic which occurred in the Faroe Isles in 1846. There 
were seventeen of these islands inhabited. Prior to April 
1846 not a single case of measles had been observed in these 
islands since 1 781 ; but within six months more than 6000 of 
the 7782 inhabitants suffered from it. Panum was able to 
trace the importation of the disease from one island to 
another, and in this way he had an opportunity of deter- 
mining the period of incubation in a very large number of 
instances under the most favorable circumstances. With 

* He gives the foUowing facts in a foot-note : — '* Snccessful inoculation with 
the hlood of measles was performed by Home, of Edinbnrgb, at the suggestion 
of Monro, m 1758 ; by Speranza, of Milan, in 1822 ; and by Michael, of Eatona, 
in 184)2. An account of Michael's experiments will be found in the Gazette 
Medicate de Paris for 1843. In all he made 1122 inoculations ; only 7 per cent, 
failed. The disease was mild ; not one of the inoculated died, although a severe 
epidemic was prevalent at the time. The primary fever appeared on the seventh 
day, and the eruption on the ninth or tenth day after inoculation. The inocula- 
tions were made with a mixture of blood and serum from the miliary vesicles, or 
with tears. More recently measles has been successfully inoculated by several 
Geiman physicians, of whom Jdrg and Wendt assert that the disease from 
inoculation is not less severe than that contracted in the ordinary way." 
Inoculation of the desquamating scales during convalescence has not pro- 
duced the disease. 



Measles. 89 

scarcely an exception the eruption of measles appeared on 
the thirteenth or fourteenth day after exposure to the in- 
iection. In other words, the incubation period was about 
ten days." 

Duration of period of invasion, — The duration of the pri- 
mary, prodromal, or catarrhal period is not constant; the 
general experience appears to be that it lasts, as a rule^ 
for three or four days, but this period is often exceeded ; in 
several of the cases communicated to the committee it was 
prolonged to five days. In Case 30, reported by Dr. J. W. 
•Carr, there was a prodromal period of seven days, during 
which there was irregular pyrexia. Trousseau believed that 
it might endure for eight days, and Watson for ten. On the 
■other hand, it may be considerably less than three days, as 
will appear from cases to be presently narrated, in some of 
which no symptoms were noticed until the day before the 
rash appeared. Dr. Squire observes that '^ the invasion stage 
of measles may be so brief as to escape notice ; ^' and he quotes 
in support of this statement the case of a girl aged six years, 
who had the rash of measles '^ with no obvious evidence of 
previous sickness, not even for an hour." 

Incubation Period. 

In a large portion of the cases communicated to the com- 
mittee it is necessary to take the day of the first appearance 
•of the rash as the only available fixed date, since in many in- 
43tances the date of the earliest symptoms was not known or 
is not stated. 

The following list contains thirty-six instances in which 
the exposure was for a short known period ; it will be seen 
that in nineteen, or 52 per cent., the subsequent interval before 
appearance of the rash was exactly fourteen days. In twenty- 
eight, or 78 per cent., the period was thirteen, fourteen, or 
fifteen days. In three cases only is the period believed to 
have exceeded fifteen days : in two (Cases 67 and 81) it 
would appear to have been sixteen days, and in one (Case 82) 
•eighteen days ; but it should be noted that in Cases 81 and 82^ 
which occurred during an epidemic in a village, the source 
from which the first case, which is believed to have infected 
all the others, derived infection is not known. In four cases 
the interval between exposure to infection and the first 
appearance of the rash is stated to have been only ten days, 
in three of these cases the dates are not given, but in othei^ 
Tespects the histories appear to be pretty conclusive ; in thd 



90 



Measles. 



fourth case tlie subject was a medical student^ and tlie possi- 
bilitity of exposure to a case in the prodromal stage cannot 
be altogether set aside. 

The true period of incubation — ^that is to say, the interval 
between exposure to infection and the onset of the earliest 
symptoms— is only shown in a few of the cases ; it varied from 
eight to fourteen days, but was most often ten or eleven days* 

Table I. — Showmg ths interval^ after a single exposure to a 
source of infection, at which the earliest symptoms {if 
stated) and the rash appeared. 



1S^ —# 


No. of dayi 


No. of 




ao. 01 


to first 


days to 


Bemarks. 


case. 


symptom. 


nah. 




43 


8 


10 


A medical student, examined several cases of measles. 


63 


— 


10 


Visited a case of measles. 


64 


— 


10 


Infector in catarrhal stage probably. 


65 


— 


10 


Ditto. 


66 


— 


12 


Infector '* ill with measles." 


68 


— 


13 


Infector ill 2 days before rash. 


69 


— 


13 


Ditto. 


114 


10 or 11 


14 


Visited patient with rash fnll out. 


5 


11 


14 


Visited patient convalescent. 


45 


11 


14 


Visited patient 3 days before rash. 


3 


13 


14 


Visited patient convalescent. 


37 


— 


14 


Ditto. 


38 


— 


14 


Interview with patient day before rash. 


39 


— 


14 


Ditto. 


46 


— 


14 


Associated with patient for 19 hours preceding rash. 


47 


— 


14 


Ditto. 


48 


— 


14 


Ditto. 


49 


— 


14 


Ditto. 


70 


— 


14 


At school with patient 2 days before rash. 


71 


— 


14 


Ditto. 


72 


— 


14 


Ditto. 


73 


— 


14 


Ditto. 


74 


— 


14 


Ditto. 


75 


— 


14 


Ditto. 


76 


— 


14 


Ditto. 


77 


— 


14 


Ditto. 


40 


10 


15 


Interview with patient 2 days before rash. 


41 


10 


15 


Ditto. 


42 


10 


15 


Ditto. 


78 


— 


15 


At school with patient 2 days before rash. 


79 


— 


15 


Ditto. 


80 


— 


15 


Ditto. 


115 


14 


15 


Visited patient with rash fnll out. 


67 


— 


16 


Interview with patient 2 days before rash. 


81 


— 


16 


At school with patient 2 days before rash. 


82 


""^ 


18 


Ditto. 



Measles. 



91 



Soinetliing may be learned also from cases in wliicli, 
though the exposure was prolonged, it began at a known 
period before the appearance of symptoms. Some of the 
cases afford evidence in favour of a short period which is, 
on the whole, very strong. They cannot, of course, give any 
facts as to unusually long periods, and it is therefore neces- 
sary to refer only to those which appear to indicate an unusu- 
ally short period. 

Table II. — Showing cases in which exposure commenced at a 

known date. 



No. of 
case. 


No. of days 
from com- 
mencement of 
enosoreto 
first symptom. 


No. of days 
from com- 
mencement of 
exposure to 
rash. 


Bemarks. 


105 
62 
96 
30 

29 

32 
33 
34 
35 
36 


4 

5 

9 

9 
9 
9 
9 
9 


7 

7 

11 

12 

13 

12 
12 
12 
12 
12 


Continuous exposure. 

Ditto. 
Associated with convalescent. 
Exposure ceased on appearance of rash ; 10 days 

from rash to rash. 
Exposare ceased on appearance of rash ; 11 days 

from rash to rash. 
Exposed in a cottage to patient with rash. 

Ditto. 

Ditto. 

Ditto. 

Ditto. 



In all these cases, with one exception (Case 96), the patient 
was exposed for some time either immediately before the 
appearance of the rash, or during its height ; and it may be 
that, as is probably the case with enteric fever (see p. 167), 
the period of incubation is really shortened when the " dose '^ 
of infection is large. Dr. Squire thinks that " a long interval 
may be looked for after a limited exposure, and that a con- 
tinuous exposure tends to shorten the interval ; ^' the case& 
in the above Table (II), also tend to support this view. In 
one, however, the infection was derived from a convalescent 
patient, and in two others the exposure ceased on the appear- 
ance of the rash, but there had been close relations during 
the primary stage. In Case 43 (see Table I) the infected 
person was a medical student who examined several cases of 
measles at a hospital, and therefore came into very close 
contact with them. 

Evidence in favour of variation in the length of the 



92 Measles, 

period of mcnbation is to be derived from the history of 
certain school epidemics reported to the committee ; the best 
example is the epidemic outburst recorded by Dr. Newman 
(Cases 68 to 82). The outbreaks recorded by Dr. Armstrong 
at Wellington College (Cases 10 to 21)^ and by Dr. Stedman 
at Leatherhead (Cases 22 to 28), also afford some evidence 
on this head, though the periods of exposure were longer. 

Table III contains cases in which the exposure to in- 
fection ceased at a known date, generally at or about the 
time of the first appearance of the rash. Any value they 
may possess attaches only to those which show unusually 
long periods. In seven cases the period of incubation indi- 
cated by the facts as reported is longer than fifteen days. 
In three of these seven cases the sufferers were pupils at a 
fichool at which a case had occurred (Cases 21,27, 28), and 
it seems very improbable that any other case, or any source 
of infection in fomites was overlooked. In Case 124, Dr. 
Squire who reports it, suggests that the period may have 
been prolonged by an intercurrent attack of influenza. In 
Cases 101 and 102 the only source of fallacy that suggests 
itself is that the infection may have been derived from 
olothes taken into use at some date after the commencement 
of the voyage, as in the epidemic of scarlet fever on board 
ship recorded by Dr. Murchison (q. v., p. 169). In Case 104 
it does not appear whether certain children who had the 
disease in the depdt before the ship started sailed in the 
fihip or no. 

In 22 of the cases the infector was isolated as soon 
as the rash appeared; the interval between such isolation 
and the appearance of the rash was as follows : — In 1 case 
ten days ; in 5 cases eleven days ; in 4 cases twelve days ; in 
& cases thirteen days; in 3 cases fourteen days; in 1 case 
fifteen days; in 1 case sixteen days; in 1 case seventeen 
days; and in 1 case eighteen days. If the most common 
interval between reception of infection and the appearance of 
the rash be taken to be fourteen days, these figures would 
appear to indicate that the liability of susceptible persons to 
contract the disease is about equally great on each of the 
three days preceding the day on which the rash is first noticed. 

With regard to the true period of incubation, that is to 
say, the interval between the exposure to infection and the 
first symptoms, it will be seen on comparing these two tables 
(II and III) that there is in many instances a correspondence 
between the duration of this period and of that intervening 



Measles. 



99 



l)etween tlie exposare and the appearance of the rash. The 
exceptions are, however, very numerous, and it does not 
appear to be possible to formulate any general rule. The 
true incubation periods shown by the cases vary within very 
wide limits, from four or five to thirteen or even sixteen days* 

Table III. — Showing cases in which exposure to infection 
ceased at a known date, showing suhsequent interval hefore 
rash or early symptoms. 



' 


Days between 


Days between 


^ 


No. of 


cessation of 


cessation of 


Bemarks. 


case. 


exposure and 


exposure and 




first symptom. 


rash. 




22 




10 


Infector removed when rash appeared. 


109 


_- 


10 


Exposure ceased day before rash. 


101 


^^ 


10 


At sea; source of infection unknown. 


10 


.. 


11 


Infector isolated when rash appeared. 


11 


— 


11 


Ditto. 


12 


..^ 


11 


Ditto. 


23 


_ 


11 


Infector removed when rash appeared. 


24 


.— 


11 


Ditto. 


18 


— 


12 


Infector isolated when rash appeared. 


14 


— i 


12 


Ditto. 


25 


.. 


12 


Infector removed when rash appeared. 


26 


— ^ 


12 


Ditto. 


95 


— 


12 


Patient removed from infected neighbourhood. 


107 


9 


13 




113 


9 


13 


A few days before measles. 


8 


12 


13 


Infector isolated when rash appeared. 


9 


12 


13 


Patient removed day after rash appeared in 
infector. 


15 


— 


13 


Infector isolated when rash appeared. 


16 


... 


13 


i)itto. 


17 


_ 


13 


Ditto. 


18 


_ 


13 


Ditto. 


31 


12 


13 


Patient removed on fourth day of infector's rash. 


103 


... 


13 


At sea ; source of infection unknown. 


110 


10 


13 


Exposure ceased day before rash. 


6 


12 


14 


Infector isolated when rash appeared. 


7 


12 


14 


Ditto. 


19 


_ 


14 


Ditto. 


108 


13 


14 




20 


— 


15 


Infector isolated when rash appeared. 


127 


11 


15 




27 


.._ 


16 


Infector removed when rash appeared. 


28 


_ 


17 


Ditto. 


21 


— 


18 


Infector isolated when rash appeared. 


124 


16 


18 




101 


..^ 


18 


At sea; source of infection not traced. 


104 


— 


19 


At sea; facts as to isolation of previous cases 
not stated. 


102 


— - 


22 


At sea; source of infection not traced. 



94 Measles. 



Duration op Infectious Pbeiod. 

A patient is infectious for several days before the appear- 
ance of the rash of measles; this is so generally accepted 
that it appears hardly to be necessary to qnote instances. A 
glance at the two tables given above will afford many, and 
Dr. Murchison^s Group III is a very striking example ; in com- 
menting on it he remarks that it illustrates " the extreme con- 
tagiousness of measles in its primary or catarrhal stage.'^ It 
may be added that the catarrhal symptoms may be of a very 
slight kind, and yet the sufferer may be able to infect others. 
In Cases 38, 39, 40, 41, 42, the symptoms were so slight that 
the persons who infected the others were able to attend even- 
ing parties. In Case 45 the child " had no symptoms which 
attracted attention." The exposure occurred in some cases on 
the first, in others on the second, and in others again on the 
third day before the rash; Cases 45, 119, and 127 are ex- 
amples in which the patient from whom the infection was 
derived did not develop the rash of measles until three days 
after the occasion on which the person who subsequently 
suffered was exposed. In Cases 40, 41, 42, 67, and 68 to 
82 the exposure took place two days before the rash. The 
same holds good for Dr. Murchison's Group III. 

Infection is much less often derived from a patient con- 
valescent from measles. The cases communicated to the 
committee, however, afford a few instances. 

^^- 0' Nature of expoBure. Interval 

case. *^ to rash. 

3. — Was, for a few hours, with children supposed to have recovered . 14 days. 
5. — Spent a few hours at a school in which there had heen an epi- 
demic ; the last case had rash 17 days before . . .14 
37. — Danced with a man just convalescent ..... 14 
44. — Contracted the disease from brothers, who had probably taken 

it from a boy who returned to school convalescent . . 12 
96. — ** Desquamating from a recent attack of measles " . . .11 
125. 1 Was in same class at school as a boy who was allowed to return 
126. J ^20 days after sickening 10 „ 

On the other hand. Dr. Squire gives two striking histories 
(Cases 121, 122, 123), which tend to prove that a patient has 
ceased to be infective three weeks after the appearance of 
the rash. 

Mode of infection. — The mode of infection in the great majo-» 
rity of cases is personal intercourse. Dr. Murchison gives a 



ft 
*» 



Measles. 95 

history (Group IV) communicated to him by Dr.Bristowe which 
fioems to prove pretty conclusively that the infection can be 
conveyed by fomites, and possibly the circumstance related 
in the second paragraph of Dr. Stretton's communication 
(see under Case 96) may be another example^ but the occur- 
rence must be rare.* 



Conclusions. 

The general conclusions which appear to be warranted 
hy the reports received are— 

1. The interval between exposure to infection and the 
appearance of the rash of measles is more often fourteen days 
ihan any other period, but it is not infrequently a day more 
or a day less. Intervals of sixteen, seventeen, and eighteen 
days probably occur occasionally, and in considering the 
question of the isolation of susceptible persons who have been 
exposed to infection the possibility of such periods cannot 
be left out of account. In rare cases the interval may be as 
Bhort as seven days. 

2. The primary, prodromal, or catarrhal stage varies in 
length from one to five days, so that in calculating the true 
period of incubation of measles a deduction must be made 
from the intervals above mentioned. The amount of this 
deduction cannot be stated in general terms, for the duration 
of the primary stage does not bear any constant relation to 
the duration of the interval between exposure and the appear- 
ance of the rash.' The true incubation period of measles is, 
in a majority of cases, nine or ten days, but may be as short 
as five or even four days, and as long as fourteen. A sus- 
ceptible person who has been exposed to the infection of 
measles must be kept under observation for a full fortnight, 
and be found free from fever and catarrh at the end of that 
period, before it can be said that the disease has not been 
contracted. 

3. Measles is vety infectious during the primary period, 
and probably not less so during the whole acute attack. A 

* It is possible that for short distances, as from one ward of a hospital to 
Another, iiijection is more easily and frequently conveyed by fomites, t. e, by the 
dresses of attendants. Farther, it is difficult to account for some of the out- 
breaks in children's hospitals except on the supposition that the infection is 
brought in by visitors. The circumstances here, however, are so complicated 
that no instances have been given in the text. The question has been discussed 
by M. Qrancher {Bull, M4d., 1889, and Bull, de la Soe, Mid. des Sdp., 1889). 



96 Measles. 

patient who has had measles is capable of conveying the in* ^ 

f ection after convalescence has advanced far enongh to enable- 
him to resume his nsnal avocations^ bnt this liability ceasea 
probably within about three weeks of the appearance of 
the rash if disinfection has been practised. 

4. There is considerable probability that fomites are cap- 
able of retaining the infection^ at any rate for a short time. 



Measles. 97 



OASES. 

Cases 1 and 2. 
Communicated by Dr. C. B. Smith, Wexford, 1878. 

A boy sent home from service, having been ill six or seven days 
with measles, arrived on February 8 ; he died on February 14, and was 
buried February 15; the house was cleaned and fumigated. On 
February 20 his brother and sister (Cases 1 avd 2) had first symptoms 
of measles. This was twelve days after inf ector's arrival, six days after 
his death, five days after his burial and the fumigation of house. No 
previous case of measles in Dr. Smith's district " for months." 

Causes 3 to 8. 

Commanicated by Dr. Lowndbs, Egbam. 

[These cases are the same as Groups 1 and II, given by Dr. Mttbchison in the 
Ik'ansactions of the Clinical Society, vol. zi, p. 242.] 

On January 7, 1878, M. {Case 3) was for " a few hours and at lunch '* 
visited by two other children who " were supposed to have recovered 
from measles." On January 10 he returned to school, where he became 
ill on January 20 (thirteenth day), and had distinct measles the next 
day, January 21. This was the first case in an epidemic in the school. 
He was isolated in sanatorium on January 21. 

The second case in this epidemic {Case 4) began to sicken on Feb- 
ruary 2 (thirteenth day from early symptoms of Case ^3); unmis- 
takable rash on February 4. 

Reporter's son, aged Itii {Case 5), visited the school to see a theatrical 
performance at which some of the boys were present. The last case in 
the school had had rash on February 18 ; the theatrical performance 
was on March 5; Case 5 was indisposed on March 15 (tenth day), 
had a cold and cough on March 16, and rash on March 19th. He was 
isolated on that day. 

Child aged 6f {Case 6), living in the same house as Case 5, was 
indisposed on March 31 (twelfth day from rash of Case 5) and had rash 
April 2 (fourteenth day). 

Child aged 4^ (jCase 7) exposed in same way as Case 6; indisposed 
March 31 ; rash April 2. 

Child aged 2^ {Case 8) exposed in same way as Cases 6 and 7 ; indis- 
posed on March 31, and had rash on April 1 (thirteenth day from rash 
of Case 5). 

Case 9. 

Communicated by Dr. H. E. Abmstbong, M. O. H., Newcastle, 1878. 

Reporter's daughter, aged 3 {Case 9), was staying in Sunderland in 
a house with two children who had measles rash on Ifovember 11. She 
was taken home to Newcastle on November 12. She was indisposed on 
November 23 (twelve days from donor's rash), had a slight rash, nature 
of which was doubted on November 24 (thirteenth day) ; was well on 
November 30. Nature of illness proved by occurrence of well-marked 
measles in her infant sister on December 12. 



98 Measles, 

Cases 10 to 21. 

Communicated by Dr. H. G. ABHSTSONa, M. 0., Wellington College, 1889. 

On February 7, 1887, the twelfth day of term, a boy appeared with 
the rash of measles, and was immediately isolated. The rash appeared 
in three boys(Ca«e« 10, 11, 12) on February 8, the eleventh day from 
inf ector's rash ; in two boys (Cases 13, 14) on February 19 (the twelfth 
day) ; in four boys (Cases 15, 16, 17, 18) on February 20 (thirteenth 
day) ; in one boy (Case 19) on February 21 (fourteenth day), in one 
(Case 20) on February 22 (the fifteenth day), and in one (Case 21) on 
February 25 (the eighteenth day). No case occurred in the village, so 
far as was known, which renders it improbable that infection was 
carried to the College from that source, and highly probable that the 
case of February 7 was the origin of the epidemic. 

Cases 22 to 28. 

Communicated by Dr. A. Stedman, Leatherhead, 1889. 

Boy, R., at school, sent home with measles rash November 12. 
Cases occurred among seven other children at the school, rash being 
"out" in one (Case 22) on November 22, in two (Cases 23, 24) on 
November 23 (eleventh day), in two (Cases 25, 26) on November 24 
(twelfth day), in one (Case 27) on November 28 (sixteenth day), and in 
one (Case 28) on November 29 (seventeenth day). The schools were 
closed on November 23, and there was an eighth case on December 5, 
but the source of infection may have been one of the children, who 
had the rash on November 22, 23, or 24. 

Cases 29 and 30. 
Communicated by Dr. J. W. Cabb, London, 1889. 

A boy, G. J., aged 1 year (Case 29), was admitted to the Yictoria 
Hospital for Children on January 28 for bronchitis ; he had not had 
measles, and his parents stated there was no measles in their house. On 
February 13 another boy was admitted to the same ward ; early on 
February 15 he " developed the rash of measles, and was at once dis- 
charged." G. J.*s temperature rose to lOO'e** F. on Februaiy 22, and 
continued between lOP and 103° F., with some diarrhoea until Feb- 
ruary 26, when the rash of measles came out, with a temperature of 
102*8° F. There had been no case of measles in the hospital for the 
two months previous to February 13. 

F. C. (Case 30) admitted to Yictoria Hospital for Children, October 3, 
from the country, for pneumonia ; he was allowed up on October 26. 
On October 29 a boy was admitted to the same ward, who on October 
31 developed rash of measles. F. C. sat beside this boy's bed on 
October 29 and 30. On November 3 his temperature rose to 103° F. ; 
irregular pyrexia continued one week, and on November 10 measles 
rash appeai*ed. 

Case 31. 
Communicated by Dr. G. W. Abmstbong, Boyal Hospital Schools, Greenwich. 

C. D., a boy aged 11, whose brother came out with measles rash on 
August 28, returned from home, where he had been with his brother, to 
school on August 31 ; had headache on evening of September 12, and 
coryza and rash on the following morning. There was no other case 
of measles in the school. 



Measles, 99 

Cases 32 to 36. 
Communicated by Dr. C. H. Watts Pabeinson, M. O. H., Wimborne. 

F., a girl, was sent home from service on November 12 ; she then 
had rash of measles out. The house was a small isolated cottage in 
a sparsely inhabited heath country. There was no case of measles in 
the neighbourhood. Nine days later, on November 21, the five other 
children (Cases 32 to 36) in the cottage became unwell, and on Novem- 
ber 24, the twelfth day, the rash of measles appeared on all five within 
a few hours of each other. 

Cashs 37 to 39. 
Communicated by Dr. Feed. Wilkinson, M. O. H., Lewisham. 

A young lady (Case 37) danced several dances with a gentleman 
just convalescent from measles on January 1. On January 14 she 
went to a children's party, and on January 15 she had the rash of 
measles. The two children (Cases 38, 39) — of different families — who 
had sat on either side of her at supper on January 14 had measles four- 
teen days later. 

Cases 40 to 42. 

Communicated by Dr. Adams Clabeb, Bushey. 

On January 7, 1889, E. C, a girl aged 10 (Case 40), was at a dance, 
and at supper sat next to a little girl who on January 9 had the rash 
of measles well out. On January 17 E. C. had headache, anorexia, 
general catarrh, and cough, and on January 22 measles-rash appeared. 
'The absence of any other source of infection than the child at the dance 
is stated to be absolutely certain. The interval to prodromal symptoms 
was ten days, to rash fifteen days. 

S. H., a boy aged 14 (Case 41), and 0. P., a boy aged 10 (Case 42), 
were at the same dance, and danced with the little girl above men- 
tioned ; they are believed not to have been exposed to infection at any 
other time. Both S. H. and C. P. sickened on January 17 (tenth day), 
and showed rash on January 22 (fifteenth day). 

Case 43. 
Dr. E. A. Welch, Worcester, Mass., U.S.A. 

D. G. H. (Case 43), a medical student, examined several cases of 
measles during a visit to a children's hospital on December 5, 1888. He 
is confident he had not been in contact with other cases " for at least a 
month previous." He had never had an attack of the disease. On 
December 12 (seventh day after exposure) he felt indisposed, had head- 
ache and coryza on December 13, and on December 15 the eruption 
began to appear on his face (tenth day). 

Cases 44 and 45. 

Communicated by Dr. F. Peabse^ London. 

On April 21 two boys, 0. and H,, returned home from school, where 
they had Deen for a week with a boy who had returned to school con- 
Talescent from measles on April 16. 0. had coryza on April 24 and rash 
on April 28. H. had rash on April 29. D. {Case 44), a younger brother 
of 0. and H., was in association with them from April 21 to April 27, 



100 Measles. 

when they were separated from D. On May 6 (twelve days after C. 
had prodromal symptoms and nine days after G. and H. were isolated) 
D. had ** a cold," and on May 10 (sixteen days after prodromata in C, 
and thirteen after C. and H. were isolated) the marked rash of 
measles developed. 

On December 25 two children, A. and B., of one family played with 
C. (Case 45), a child of another family. A. at that time had no sym- 
ptoms which attracted attention, but on December 28 A. had rash of 
measles (B. had rash on January 8). On January 5, the eleventh day 
from playing with A., 0. was " taken poorly," and on January 8, the 
fourteenth day from playing with A., showed the rash of measles un- 
mistakably. B., though exposed earlier and later than C, was appa* 
rently infected at the same time. 

• 
Cases 46 to 50. 

Communicated by Dr. Clbmbnt Dukes. 

P., a boy, returned to school on January 19, 1888, at 7 p.m., coming^ 
from a village where there was measles. He mixed with his fellows 
for nineteen hours, i. e, up to 2 p.m. on January 20, when Dr. D. found 
him ** covered with rash," and took him to hospital. On February 2, 
fourteen days fromP's return, four other boys {Cases 46, 47, 48, 49) had 
the rash of measles, and were isolated. These five boys were all at the 
same master's house. There was, however, another centre of infection 
in the school at this time, but in a different master's house, viz. : — 

P., a boy who returned to school on January 19, had measles rash 
on January 23, and was isolated on that day. On February 4, B., a 
boy {Case 50) who lived in the same study as P., had the rash, i, e, six- 
teen days after P. returned to school, and twelve days after he was 
isolated. 

Cases 51 to 54. 

Communicated by Surgeon Baeeb, A.M.D. 

An epidemic among soldiers' children in barracks, introduced by 
children living in the town (Winchester), but attending the regimental 
school. V. was ailing on October 29, and had rash on November 1. 
Cases 51 and 52 were a sister (aged 3 ) and brother (aged 7 months) of 
V. ; both sickened on November 10 (twelve days after first symptoms 
in y.), and had rash on November 13 (fifteen days after first sym- 
ptoms in v.). 

Same epidemic. X. was ailing on October 27, and had rash on 
October 30. Case 53, his sister, aged 3, was ailing on November 9 
(thirteenth day from first symptom), and had rash on November 11 
(fifteenth day). Case 54, a boy aged 1 year and 5 months, lived, in a 
room immediately above X. ; he was ailing on November 11 (fifteenth 
day from first symptoms in X., and had rash on November 14 (eigh- 
teenth day). 

Cases 55 to 61. 

Communicated by Dr. J. W. Allen, Hampstead. 

' An epidemic in a family. The first case had rash on January 4, 
after prodromal symptoms for three days; source of infection un- 
known. Case 55 had rash on January 13 (ninth day from rash) ; 



Measles. 101 

Cases 56, 57, 58, 59 on January 14 (tenth day) ; Cases 60 and 61 on 
January 19 (fifteenth day). 

Case 62. 

Communicated by Dr. F. R. Humfhbby. 

'' N. H., aged 4, retui*ned home on August 29 from a measles-in- 
fected locality. Developed measles rash and a cough on September 2. 
The baby sister {Ca>se 62) of N. H. was taken ill on September 5 with 
measles, only sui'viving a few days." 

Cases 63 to 65. 
Communicated by Dr. W. Vaudbbt Lush. 

'' A. T. {Case 63), an adult, visited a case of measles. Ten days 
afterwards eruption appeared on A. T." 

0. T. and E. L. {(fases 64, 65), both adults, entered a shop together 
in a room off which was a child coughing ; " shopkeeper stated that 
she thought her child was going to have measles." Ten days after- 
wards the rash of measles appeared on both 0. T. and E. L., who had 
parted company on the day of their exposure to infection. 

Case 66. 

Communicated by Dr. P. O'Connall, Chicago. 

On the evening of January 20, 1889, " Eddie M., aged 3 years, spent 
fifteen minutes in a room with a child sick with measles. On February 1 
the rash of measles began to appear on his face. Neither directly nor in- 
directly was there any previous or subsequent exposure to infection." 

Case 67. 
Communicated by Dr. Vachell. 

A groom (Case 67) spent two nights and a day at the village of 
Peterstow, at a time when there was an epidemic of measles in a 
neighbouring village two and a half miles away. Two children of the 
Peterstow station-master's were attending school at the infected village, 
and developed measles rash on Februaiy 20. The groom spent some 
time in the company of these children on February 18. On March 5, six- 
teen days later, the groom developed measles rash at the house where 
he was employed near Cardiff (nine miles from the village where the 
•epidemic was). 

Cases 68 to 94. 

Communicated by Dr. W. Newman, Stamford. 

On Sunday, December 30, 1888, seventeen children were together at 
a small Sunday school. One child, then unsuspected, showed measles on 
Tuesday, January 1, 1889. One child had had measles before, and 
escaped infection. The remaining fifteen (Cases 68 to 82) took measles 
in the order indicated in the following table, in which the date of each 
•case is given ; the table shows in a graphic manner the relative fre- 
quency of attacks on the several days. Thus there were 2 on the 
thirteenth day, 8 on the fourteenth day, 3 on the fifteenth day, 1 on 
the sixteenth day, and 1 on the eighteenth day. 



102 Measles. 

Jan. 15 Jan. 17 



Jan. 12 


Jan. 13 


Jan. 14 


Jan. 12 


Jan. 13 


Jan. 14 




Jan. 13 


Jan. 14 




Jan. 13 






Jan. 13 






Jan. 13 






Jan. 13 






Jan. 13 





Dr. Newman also gives the following cases : 

Exposed to infection on fiash appeared 

A (C(ue 83).— Dec. 27, 1888 ... Jan. 7, 1889 ... 11 days. 
B {C(Me 84).— Jan. 6, 1889 
C (Case 85).— Jan. 6, 1889 
D (Case 86).— Jan. 7, 1889 



E (Case 87).— Jan. 17, 1889 



Jan. 17, 1889 ... 11 „ 
Jan. 17, 1889 ... 11 „ 



Jan. 18, 1889 ... 11 „ 
Jan. 26, 1889 ... 9 „ 



In a family of eight children one was taken ill with measles ; twelve 
days after four children (Cases 88, 89, 90, 91) showed the rash. Twelve 
days after these four, the remaining three children (Cases 92, 93, 94)» 
showed the rash. 

Case 95. 

Communicated by Dr. J. H. Gobnall. 

A boy, aged 12 (Case 95), received serious contusions in a railway 
accident on March 1, and was admitted into the Warrington Infirmary 
on that day. On March 13, while still in hospital, and convalescing 
from the accident, and without so far as was known being exposed to 
contagion in the hospital, he " broke out with measles, with the usual 
symptoms, coryza. Sec.*' Measles had been prevalent in the neighbour- 
hood where he lived, but he had not been visited by anyone except 
his parents. 

Case 96. 
Commanicated by Dr. Stbetton. 

A girl, X., aged 11, returned home from school on March 14, 
desquamating from a recent attack of measles. A boy, aged 2^ (Cas& 
96), was in the room when this girl was undressed on March 14 ; he 
" came out with full crop of measles on March 25.*' The period of 
incubation cannot have been more than eleven days. 

A dressmaker finished some dresses while herself ill in bed with 
measles. The lady who received them occupied the same bedroom as 
her niece ; the dresses were shaken out and placed on the bed. The 
niece had measles within about (probably) twenty-four or twenty-five 
days. Another girl (X. of last instance), on December 26, 1878, slept 
in the room previously occupied by the aunt and niece. X. had measles 
rash on or about January 18. (Dates are from patient's memory.) 

Case 97. 

Communicated by Dr. F. W. Thubnam. 

A boy, A., aged 3^ (Case 97), was admitted into the London Fever 
Hospital on January 19th, suffering from the afber effects of scarlatina, 
with which he had been attacked fourteen days earlier. He was placed 



Measles. 103 

in a scarlet fever ward in which several cases of measles had not lone 
before broken out. On January 23 a patient in this ward developed 
symptoms of measles. On January 24> A. was removed to another 
ward. On February 6 his temperature rose to 101 6° F. On February 7 
there was indistinct rash and slight coryza ; on February 8 the rash was 
well marked (sixteen days after rash in earlier case, fineen days after 
removal from infected ward, and twenty after admission to hospital). 

Cases 98 to 100. 
Communicated by Dr. G. C. Hbndebson. 

A scarlet fever ward in the London Fever Hospital became infected 
with measles, through certain children who developed measles from a 
week to ten days after commencement of scarlet fever. 

On December 13 "N. M., aged 3 {Case 98), was admitted into this 
ward suffering from scarlet fever ; he was convalescent on December 17, 
but his temperature rose again on December 27, his face became puffy, 
conjunctivsB injected, and cough and coryza set in. On December 31 
measles rash appeared. (First symptom fourteen days after admission, 
rash eighteen days after.) 

On December 24 David W. {Case 99), aged IJ, suffering from scarlet 
fever, was admitted into the ward. He was convalescent on Decem- 
ber 27. On January 7 his temperature rose to 102*2° F., and he had 
cough, coryza, injection of conjunctivae, and puffy lips. On January 11 
a faint papular rash, which was distinctly that of measles next day, was 
noticed. (First symptoms fourteen days after admission, rash eighteen 
days after admission.) 

Percy B., aged 8 {Case 100), suffering from scarlet fever, was 
admitted to the same ward on January 8. He was convalescent on 
January 11. On January 23 his temperature rose to 103° F., and he 
was sick and out of sorts. On January 26 a measles rash appeared. 
(First symptoms fifteen days after admission, rash eighteen days after 
admission.) 

Cases 101 to 104 
Communicated by Dr. W. H. Psabsb, Plymouth. 

Ship " Oasis," Calcutta to Demerara, carrying 249 men, 76 women, 
43 children between one and ten years, and 33 infants, sailed on 
September 2, 1865. On September 20 a European apprentice {Case 101) 
showed measles, and on September 24 a coolie child {Case 102). These 
dates are those on which the eruption first showed. There were no 
other cases. (The first case eighteen days, and the second case twenty- 
two days after sailing.) 

Ship " Hamburgh," Plymouth to Melbourne, carrying 412 persons, 
including 86 children under twelve, of whom 54 were under seven years, 
sailed on July 31, 1870. The children entered the dep6t at Plymouth 
on July 25, and had no subsequent communication with " the outside 
world.'' The first case of measles (Case 103) occurred on August 7 
(thirteen days after entering the depot). 

Ship "Liverpool," Calcutta to Trinidad, carrying 538 persons, 
including 35 children and 9 infants. Passengers entered the dep6t on 
September 4, 1867, and had no subsequent communication with the 
outside world. While in dep6t four cases of measles occurred among 
the passengers of this ship and others, 1000 in all, in the dep6t. The 



104 Measles. 

ship sailed on September 7 ; the first case of measles {Case 104) showed 
itself on September 23 (nineteen days after entering dep6t). It does 
not appear, however, whether the four patients ill at the dep6t or any 
of them sailed in the " Liverpool." 

Cases 105 to 127. 
Commnnicated by Dr. William Squibs.* 

A girl, B. {Case 105), aged 12, returned home on January 24, 1865, 
after an absence of at least three weeks ; a younger sister had com- 
menced to be ill with measles on January 19, and had the rash on 
January 22. B. had feverish disturbance on January 27, catarrhal 
symptoms on January 28, and rash on January 31, seven days after 
return home. Another sister {Case 106), much with the first sufiPerer, 
and a brother who sickened at the same time and had also been exposed 
throughout, had the rash on February 1, a day after their sister B., 
whose exposure commenced at a later date. 

A boy, aged 7^ {Case 107), attended school daily until October 24, 
1868, on which day one of the boarders complained of illness, which was 
known to be measles on October 26. Case 107 was not at the school on 
October 25 or 26, but called for his books on October 27. He vomited 
on October 31, was ailing on November 2, and had full rash on Novem- 
ber 6 — thirteen days after last day at school. His brother {Case 108), 
aged 5, was last at school on October 24, had initial fever on Novem- 
ber 2, high fever on November 6, and rash on November 7 — fourteen 
days after last visit to the school. A sister, aged 6, of these two boys 
{Case 109) was with them until November 4, when she was not allowed 
to enter their room, and was removed to another house on November 5. 
She had the rash on November 15, ten days after complete isolation. 
Another brother, aged If {Case 110), isolated at the same time as 
Case 109, had the rash on November 18, thirteen days after isolation. 
He had begun to be ill on November 15. 

A boy, aged 12 {Case 111), left school, where there had been measles, 
on March 20, 1869. He was dull on March 27, and had rash on 
March 30, ten days after the cessation of exposure. A boy, aged 6i 
(Case 112), was with Case 111 from March 26 to 29 ; he had some initial 
fever on April 4, the usual symptoms on April 7 and 8, and full rash on 
April 9, eleven days after cessation of exposure, and fourteen after its 
commencement. 

A girl, aged 6 {Case 113), until May 10 was much in the company of 
a child who had measles a few days later. Case 113 had fever on 
May 19, cough on May 21, coryza and rash on May 23, thirteen days 
after cessation of exposure. 

A girl, aged 4 {Case 114), on February 19, 1872, was taken to see a 
brother in another part of London, but only remained half an hour, as 
he was found to have the rash of measles full out. Ten days after, on 
March 1, she sneezed, on the next day she had headache, and on 
March 4, fourteen days after exposure, gJie had the rash full out. A 
brother, aged 8 {Case 115), exposed in the same way, complained of 
illness on March 4, and the rash began to appear on the following day, 
fifteen days after exposure. 

* Cases 105 to 123 have already been published by him in his Essays in 
JPreventive MedicinSf p. 64, et seq. 



Meddles. 105 

Infection during catarrhal stage, — ^A girl, aged 6 {Ca^ae 116), ceased to 
attend school on November 25, had the £*st signs of measles on 
December 4, 1871, nine days after last attendance, and the rash on 
December 6, eleven dajrs after last attendance. A girl, aged 6 
{Caxe 117), visited thi^ girl on December 3, when she had cough only. 
On December 14 Case 117 was ill, and had rash of measles on Decem- 
ber 17, fourteen days after exposure. A boy, aged four {Cobb 118), 
brother of last case, was exposed in the same way and at the same time ; 
he had the rash on December 14, eleven days after exposure. 

Infection in prod/romal stage, — ^A boy on a visit was ailing on 
February 13, and was sent home ; he had rash of measles on February 16. 
From February 9 to 12 he slept in the same room as a girl aged 10 
{Case 119), but was separated from her on that day. She had fever on 
February 20, coryza on February 24, twelve days after cessation of 
exposure, and rash on February 24. 

A boy, aged 6 {Case 120), ceased to attend school on November 17, 
1871, on account of measles and whooping-cough in the school. He 
<;oughed and was sick on November 29, was feverish on December 4, 
had the first signs of measles on December 5, and the full rash on 
December 6, nineteen days after ceasing to attend school. 

Limited duration of infection. — Two girls, aged 14 and 11 (Cases 121 
and 122), were brought home from school with the rash of measles fully 
out on January 30, 1872. Three other children remained in the house 
while these two girls were ill, but were isolated. After three weeks the 
two girls were allowed to mix with these three children, as well as with 
two others that had been sent away ; no fresh cases occurred, showing 
apparently that the two who suffered had ceased to be infective. 

A boy, aged 9 (Case 123), who had measles at school was allowed to 
return home and mix with his eight brothers and sisters exactly three 
weeks after his rash had been at its height. His clothes had been 
** efficiently exposed " to the fumes of burning sulphur, and he had 
washed with carbolic soap. None of his brothers or sisters took 
measles. 

A lad, aged 15 (Case 124), was staying in a house in which a case of 
measles occurred on January 2, 1890. The case was isolated that day, 
and Case 124 was sent to London on January 4; on the following day 
he had influenza.* He had some fever again on January 12; on 
January 20 he had bronchitis, sixteen days after cessation of all ex- 
posure, and eighteen after isolation of the case from which he is believed 
to have contracted measles. The rash appeared on January 22. Dr. 
Squire suggests that in this case the incubation period of measles was 
lengthened by the intervening attack of influenza. 

R., a boy aged 14, sickened with measles at school on January 21, 
1888, and was isolated until February 10, when he went back to his 
olass. Two fresh cases (Cases 125 and 126) occurred on February 20 ; 
the interval between exposure and sickening was ten days. 

B. H. sickened for measles on October 20, 1888, and had the full 
rash on October 24. His sister, F. H. (Case 127), who was much with 
him on October 20 and 21, had fever on November 1, couffh on Novem- 
ber 3 and 4, and rash on November 5, fifteen days alter assumed 
<}essation of exposure. 

* See Influenza, Case 78. 



106 Measles. 

The following cases were communicated to the Society by Dr. Mubohisok in I 

1878. i 

Gboup III. — ^There was a party of about twenty children at the 
house of Mr. D. One of the children was in what turned out to be the 
second day of the catarrhal stage of measles, the rash not appearing- 
until a day or two later. About twelve days afterwards almost all of the 
remaining children who were at this party were attacked with measles- 
Two of uiese children, while suffeiing from catarrh, but two da^s 
before the appearance of the rash, were present at another juvenile 
party at the house of Mr. F., and fourteen days afterwards several of 
the other children who attended this party sickened with measles, the 
rash of which appeared four days later. 

Group IV. — In the spring of 1876 a little girl who had been away 
for the Easter holidays returned to school. She came about 2 in the 
afternoon, and was sent home about 6 on the same day, either because 
she had the rash of measles upon her, or because she was ill with sym* 
ptoms which developed later into measles. At that time all Dr. B.'s 
children, excepting the three youngest, had had measles, and five of 
those who were not susceptible were attending the school. When» 
dressed to come home at 4 o'clock Dr. B.'s eldest daughter went and 
talked to the little girl referred to on the stairs, and on reaching home 
the eldest of the three susceptible children went into her bedroom and 
helped her to put her clothes away. That day fortnight this little girl 
sickened with measles, and on the same day several of the pupils at 
the school were also attacked. About a fortnight later Dr. B.'s two- 
youngest children were taken ill with what was thought to be a very 
slight attack of measles. 



MUMPS. 

IN attempting to ascertain the duration of the period of 
incubation in mumps some uncertainty must arise owing^ 
to the indefinite character of the earliest symptoms, those, 
namely, which occur before a distinct swelling of the parotid 
can be observed. Though ill- defined, and often very slight, 
a person who is suffering from them is capable of infecting 
others. A patient will frequently assert that he has been 
perfectly well until the sudden onset of the disease with high 
temperature and pain in the parotid region ; in many, in fact 
in the majority, of the cases communicated to the Committee 
the only date known is that of the commencement of swelling- 
in the glands ; it has, therefore, been necessary to calculate 
the interval between exposure to infection and the appearance 
of the parotitis. 

Incubation peeiod. 

The incubation period of mumps is generally said to 
extend to two or three weeks; the cases contained in this 
report tends to prove that it approaches more nearly, as a 
rule, to the latter than to the former. 

In Table I have been brought together all the cases in 
which the disease followed a single short exposure. The cases 
are fourteen in number ; in nine the interval between exposure 
and the parotid swelling was about three weeks, a day or two 
more or a day or two less; to this number Case 88 may be added, 
in which the date of the first symptoms is stated to have 
been eighteen days after exposure. In three cases, however, 
the interval was more nearly two weeks. The cases, however, 
are too few in number to warrant us in drawing any conclu- 
sions, and it becomes necessary to rely chiefly upon cases in 
which exposure ceased at a known date. The number of such 
cases is large, and the Committee is especially indebted to 
Dr. Clement Dukes for a long and valuable series. Taking 
all the cases of this kind it will be found that every interval. 



108 



Mumps. 



from twelve to twenty-five days, is mentioned by one or other 
of the observers who have communicated with the Committee. 

Table I. — Showing the cases in which the disease followed after 
a stated interval a single or short exposure to an infected 
person. 

No. of days between exposure and 



No. of case. 
9 • 


First symptom. 
11 




Swollen face. 


121 


— 




14 


122 


— 




16 


2 


— . 




17 or 18 


88 


18 




— 


83 


— 




20 to 22 


5 


— 




21 or 22 


6 


— 




21 or 22 


84 






21 to 23 


50 


— 




22 or 23 


15 


— 




23 


49 






23 to 25 


85 


— 




23 to 25 


86 


— 




23 to 25 



In the following table the Nos. of the cases are arranged 
under the various days ; the height of each column will indicate 
approximately the relative frequency of the onset of the paro« 
titis on each day : 













Table II 


t 




























4 
117 


























113 


116 


























112 


115 


























111 


114 
























107 


110 


71 
























106 


109 


65 
























105 


108 


59 
























104 


64 


58 


123 






















91 


63 


56 


118 




















103 


76 


61 


54 


77 


134 


















102 


75 


52 


53 


68 


120 


















101 


74 


47 


37 


67 


119 


















100 


60 


46 


85 


66 


78 






82 








98 




99 


45 


42 


29 


44 


72 






81 








90 




55 


39 


41 


28 


48 


69 


80 




70 






135 


83 


62 


84 


88 


40 


27 


82 


25 


79 




57 




17 


89 


18 


51 


19 


36 


31 


1 


80 


24 


73 


15 


26 


48 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 



Days . 

The only cases of this order which do not appear in 
the above table are the very exceptional group Cases 10 to 



Mumps. 109 

14 ; it is^ perhaps^ legitimate to suspect that there may have 
been some undiscovered source of infection at a later date 
in these cases, standing as they do separated from all others 
by an interval of at least a week. 

Attention may also be directed to cases in which the 
person infected has been exposed to a source of infection con- 
tinuously, or at least for several days at the commencement 
of the illness in the infector. Evidence has been met with 
in certain other diseases that the period of incubation may, 
under such circumstances, be shorter than after a short 
exposure. In mumps, however, there is no distinct evidence 
of such an occurrence, though the dates in the cases contained 
in the following table, which is arranged on the same prin- 
ciple as the preceding one, are not incompatible with the 
hypothesis indicated : 









Table III. 














127 
















96 
















17 


96 














16 


93 129 














8 


92 128 130 


131 








124 


7 


3 


18 94 19 


97 




132 


133 


A 


A 


A 


AAA 


A 




A 


A 


14 


15 


16 


17 18 19 20 


21 


22 


23 


24 25 



Days 

Though the number of cases is too few to warrant any 
direct statistical comparison between the two tables, it may be 
observed that the shortest and average periods of incuba- 
tion in the cases of prolonged exposure are well within the 
limits indicated by the cases in which exposure was of 
brief duration, or ceased at the time of onset of distinct 
symptoms. 

Taken together, the facts embodied in the above tables 
show that account must be taken of the possibility of a period 
of incubation exceeding three weeks in estimating the length 
of time for which a susceptible person, who has been exposed 
to the infection, must be kept under observation before he 
can be declared free from the liability to develop the disease. 
A period of observation of four weeks, however, is, probably, 
ample. The statement might be made absolute were it not 
for the cases numbered 10 to 14, which seem to show that the 
incubation period may be extended for at least a week beyond 
the four weeks above mentioned ; these cases are, however, 
as has already been pointed out, quite exceptional, and the 



110 Mumps. 

«,ssumed long interval may be due to some error of observa- 
tion, of the kind suggested above. 

Duration op Infectiousness. 

The cases sent to the Committee afford ample proof, if 
€uch were needed, that mumps is infectious at a very early 
^tage. Thus, in the series of cases communicated by Dr. 
Clement Dukes, the infector was in every instance isolated in 
the school sanatorium as soon as he complained of illness or 
was observed to be ill. In Cases 4, 5, 6, 24, 25, 26, 83, 84, 85, 
86, and in Dr. Stedman^s cases (98 — 120) the infection must 
have been derived from a case in a very early stage. Certain 
of the cases also show that the infection maybe conveyed before 
any complaint is made, and when the person about to suffer 
believes himself to be in perfect health. Examples of this 
are afforded by Cases 2, 13, 14, 15, 50, 83, 84, 85, 86 ; in one 
case (15) there is a presumption that the infection was derived 
from children at least four days before they had mumps. 

Evidence of secondary value in favour of the conclusion 
that mumps is most highly contagious in the early stage may 
be drawn from the cases in which exposure to the infected 
person continued throughout the illness, or for a considerable 
period. It will be seen from an examination of these cases, 
which are collected in Table III, that the interval given is com- 
patible with the assumption that the disease was contracted, 
either while the infector was in an early stage of the developed 
disease, or, possibly, during the few days before the parotitis 
declared itself. The shortest period between the occurrence 
of parotitis in the infector and in the infected person is fourteen 
days, and the longest twenty-five days — ^both dates within 
the limits which, on other grounds, must be assigned for the 
variation in the period of incubation in mumps. 

In no one of the cases was the infector in a late stage of 
the disease or convalescent, unless Case 9 be an exception ; in 
this case the child from whom the infection is believed to have 
been derived had been ill nine days, and the period of incuba- 
tion, according to the facts stated, was shorter than usual — 
•eleven days ; some suspicion may be felt as to whether the 
patient may not have been exposed to some other source of 
infection at an earlier date, for the case is exceptional in two 
respects — ^the assumed short period of incubation, and the 
stage of the disease in the supposed infector. 

Direct evidence that infection does not persist during 



Mumps, 111 

tjonvalescence is afforded by Cases 136 and 137. In these 
t5ases boys returned home, and associated with other children, 
a fortnight and three weeks, respectively, after the date of 
■onset of the parotitis, yet none of these other children were 
infected. 

It would appear also that very simple precautions are 
^sufficient to prevent the spread of the disease. Dr. Clement 
Dukes* cases, on the whole, prove this, since in a school, with 
many susceptible boys associated together more or less inti- 
mately, it was generally possible to discover some more than 
<3ustomary closeness of intercourse between the first cases and 
the boys who subsequently suffered. In the interesting 
family epidemic reported by Dr. C. E. Hoare (Cases 16 to 26) 
two distinct outbreaks occurred ; four cases commenced from 
sixteen to twenty days after the onset of parotitis in the first 
case, and seven more cases began from nineteen to twenty- 
four days after these four cases. Here isolation, though only 
in the same house as the patient, and not commenced until the 
day on which mumps was recognised (the third day of illness 
in this case) was effectual as regards seven out of ten persons 
who were all susceptible. 



Conclusions. 

(1) The interval between the exposure to the source of 
infection and the onset of parotitis in mumps is most commonly 
about three weeks, a day more or a day or two less. It is 
occasionally as long as twenty-five days, and more rarely as 
short as fourteen days. 

(2) The primary or prodromal stage is of very uncertain 
duration, it may last three or four days or may be entirely 
absent. In practice, in order to obtain a fixed date from which 
to make calculations, it is necessary to take the date of onset 
of the parotitis. 

(3) Mumps is very infectious at the time of onset of the 
parotitis, and during the prodromal stage which, in order to 
t)e on the safe side, should be assumed to be four days. The 
chance of infection diminishes progressively from the onset 
of parotitis, and has ceased three weeks after that date, and 
probably earlier (a fortnight). 

(4) The isolation of mumps presents no difficulty, and, even 
when it consists only in keeping the patient to his own room, 
is very commonly effective* 



112 Mumps. 

(5) Since a person about to suffer from mumps is not 
infectious until at most four days before the parotitis appears^ 
it is possible^ by isolating a person first seen ten days after 
his exposure to infection^ to ensure that he shall not infect 
others ; further, since the incubation period is most commonly 
nineteen to twenty-one days and is sometimes twenty-five 
days, it is well worth while to isolate a person who has 
been exposed to infection a fortnight or even three weeks, 
earlier. 



Mumps, 113 



CASES. 

Cases 1 to 6. 
Communicated by Dr. W. H, Bsoadbent. 

A boy (Case 1) at a scbool where an epidemic of mumps had begxm 
on November 8, was removed from school on December 15 ; he had 
been specially exposed during the early pai*t of the outbreak; the 
number of cases was greatest between December 14 and 19, four to six 
oases occurring daily. On January 2, when supposed to be safe, he was 
taken with his sister to stay with relatives at a distance, and on 
January 3, in the morning — nineteen days after cessation of exposure 
^—symptoms of mumps were apparent, and he and his sister were sent 
home. On Janury 19 or 20 one of the cousins {Case 2), with whom he 
had been for a few hours on January 2, had mumps. On January 19 
the sister of Case 1 (Case 3) had a stiff neck, and on January 21 unmis- 
takably mumps. (Case 1 had been away from school nineteen days 
when mumps developed; Case 2 developed mumps seventeen or 
■eighteen days after seeing the boy for a few nours ; Case 3 developed the 
;&rst symptoms of mumps sixteen days after her brother had parotitis.) 

A girl, aged 15, and a boy, aged 12, who had been in the same house 
'with another brother and sister suffering from mumps, were sent away 
from home together, and on January 21 arrived at the house of cousins 
in the country ; but on January 22 the boy complained of a little dis- 
comfort in the neck, and on January 23 was sent home in a very early 
stage of mumps. On February 11, nineteen days after the departure of 
her brother, the sister (Case 4) he left behind, and on this day or the 
next, twenty-one or twenty-two days after commencement and nine- 
teen or twenty after cessation of exposure, two cousins (Cases 5 and 6) 
V7ere found to have mumps. 

Cases 7 to 9. 

Communicated by Dr. Fbed. A. Bbst. 

A child visiting at Y.'s house was taken ill with mumps on March 8. 
A servant (Case 7) in Y.'s house was taken ill on March 23 (fifteen days 
after the child), and Mrs. Y. (Case 8) on March 24 (sixteen days after 
the child). A lady (Case 9) who visited the house on March 17 and 
left the same day, was taken ill on March 28 (eleven days after expo- 
.sure). There were no other cases in the neighbourhood, nor in that to 
which the visitor went. 

Cases 10 to 15. 
Communicated by Mr. Lewik Hill. 

A., staying in G.'s house, was, on Januaiy 3, found to have mumps. 
^.p B.3, B.3 (Cases 10, 11, 12), who were staying in the same house, were 
separated from A.^ on January 3, and left G.'s house on January 5. 
3.1, B.g, and. B.3 began with mumps February 6 to 8 (thirty-five to thirty- 
seven days after being separated from A.p and thirty-two to thirty-four 
days after leaving G.'s house). A.3 had mumps " a few days " after 
January 16. 

Ci and C.3 (Cases 13 and 14), children of a third family not residing 
in G.'s house, spent the evening with A., on January 2 — the day before 

H 



114 Mti^mps. 

he was found to have mnmps — and were also in company with A., on 
three or foar occasions between January 3 and January 16. O.^ and O.^: 
had mumps February 6 to 8 (thirty-five to thirty-seven days after 
exposure fco A.^, and an unstated period, but not less than twenty-one to 
twenty-three days, after being in the company of A.,). 

D. (Case 15) spent the evening at O.'s house on February 2 (at least 
four days before C.| or C.^ had mumps). D. had mumps on February 25- 
(twenty-three days after the visit to G.'s house). 

Cases 16 to 26. 
Communicated by Dr. C. E. HoAB. 

Epidemic in a family. The first case, A., took ill on November 30^ 
while the family were staying in lodgings, and had mumps on Deceml 
ber 2, 1887 ; the mother (vase 16) remained with this child until 
December 8, when she returned home. She had mumps on December IS 
(ten days after leaving A., sixteen days after A. had mumps, and 
eighteen days after A. began to sicken) ^ 

All the remaining meuibers of the family were isolated from A. on 
December 2 (the day he first had mumps), and left the house in which 
he was on December 6. B. {Ca>se 17) had mumps on December IS 
(twelve days after leaving the house in which A. was, sixteen davs after 
A. had mumps, and eighteen days after A. began to sicken). G. {Case 
18) had mumps on December 20 (fourteen days after leaving house in 
which A. was, eighteen days after A. had mumps, and twenty after he- 
began to sicken). D. {Case 19) had mumps on December 22 (sixteen 
days after leaving the house in which A. was, twenty after A. had 
mumps, and twenty -two after he began to sicken). 

B. {Case 20), F. {Case 21), G. {Case 22), and H. {Case 23), who were- 
in the same house as the mother, B., G., and D., but isolated, had 
mumps on January 6, 7, 7, and 8 respectively (nineteen, twenty, twenty^ 
and twenty-one days respectively after the mother and B. began). . 

J. {Case 24), K. {Case 25), and the father {Case 26), left home on 
December 18, the day that the mother and B. began. J. and K. had 
mumps on January 8 (twenty-one days after leaving home), and the- 
father on January 11 (twenty-four days after leaving home). 

Cases 27 to 80. 
Communicated by Dr. Clbmbnt Dukes. 

G., residing at Mr. H.'s house at Rugby School, had mumps on 
October 17, 1873, and was at once removed to the sanatorium. B.^ 
{Case 27), P. {Case 28), and S. {Case 29), in the same house, had mumpa 
on November 5 (nineteen days after G. was isolated), and B.^ {Case 30), 
in the same house, on November 6 (twenty days after G. was isolated). 

W., in Mr. A.'s house, had mumps on October 14, 1873, and was 
removed to the sanatorium. T. {Case 31), in the same house, had mumps 
on November 1 (eighteen days after W. was isolated). 

W., in Mr. M.'s house, had mumps on October 31, 1873, and waa 
isolated. D. {Case 32), in the same house, had mumps on November 20, 
twenty days after W. was isolated. 

F., in Mr. W.*s house, had mumps on November 2, 1873, and was 
isolated. The following cases followed in the same house : — L. {Case 33> 
on November 16, fourteen days after F. was isolated; H. {Case 34) on 



Mumps. 115 

November 18, sixteen days; P. (Ccbse 35) on November 21, nineteen 
days after F. was isolated. 

M., in Mr. E.'s bouse, bad mumps on January 26, 1875, and was 
taken to tbe sanatorium. The boys wbo slept in tbe beds on eitber 
side of M. both bad mumps — tbe one, D. (Case 36), on February 12, seven- 
teen days after M. was isolated, tbe otber, S. (Case 37), on February 14, 
.nineteen da^s after M. was isolated. 

B. maj., in Mr. A.'s bouse, bad mumps on Marcb 4, 1875, and was at 
once removed to tbe sanatorium. Tbe following cases followed in tbe 
saine bouse : 

y. {Case 38) sickened Marcb 21, 17 days after B. maj. was isolated. 

R. min. (Case 39) „ 21, 17 „ „ 

V, {Case 40) „ 22,18 

H. {Case 41) „ 22, 18 „ „ 

0. {Case 42) „ 22, 18 

R. {Case 43) „ 24, 20 

T. {Case 44) „ 24, 20 



ft tf 

tt »» 

»> »» 



O., in Mr. B. S.'s bouse, bad mumps on Marcb 3, 1875, and was sent 
to tbe sanatorium. N. {Case 45), in tbe same bouse, bad mumps on 
Marcb 20, seventeen days after O. was isolated. 

M., in Mr. H.'s bouse, bad mumps on Marcb 7, 1875, and was sent to 
sanatorium. H. and C. {Cases 46 and 47), in tbe same bouse, bad mumps 
on Marcb 25, eighteen days after M. was isolated. 

E., in Mr. G.'s bouse, sickened witb mumps on May 26, 1877, and 
was removed to tbe sanatorium. L. {Case 48), wbo sbared tbe same 
study, sickened on June 20, twenty-five days after £. was isolated. 

0. returned to school from home on January 24, 1878, and sickened 
witb mumps on January 26, on whicb day be was taken to tbe sana- 
torium. U. {Case 49), in tbe same bouse, wbo bad been witb C. most of 
tbe time from January 24 to January 26, sickened on February 18, 
twenty-tbree days after 0. was isolated and twenty-five days after 0. 
bad returned to school. 0., wbo bad been at Mr. V.'s private school, 
paid visits to it on January 24 and 25. B. maj. {Case 50), wbo saw 
0. at this (V.'s) school several times on tbe above-mentioned dates, 
sickened on February 14 and was reported witb mumps on February 16, 
twenty -two days after last seeing C. 

Tbis B. maj., wbo was isolated on^February 16, started an epidemic 
in Mr. Y.'s school, tbe cases sickening as follows : 

B. min. {Case 51), bis brother, on Marcb 3, 15 days after B.maj. was 

isolated. 

C. min. {Case 52) on Marcb 6, 11 days after B. ms^. was isolated. 
0. (Ca«e53) „ 7,19 

S. (Case 54) „ 7,19 

C, aged 14, at Mr. A.'s bouse, bad mumps on Marcb 10, 1878, and 
was sent to sanatorium. Tbe following cases subsequently occurred in 
tbis bouse : 

B. {Case 55) sickened on Marcb 26, 16 days after O. was isolated. 

S, {Case 66) „ „ 29,19 

L. (Case 57) „ April 3. 24 

M. developed mumps on May 10, 1878. His brotber {Case 58), wbo 
went to anotber scbool on tbis day, developed mumps on May 29, nine* 
teen days after last seeing M. 



116 Mumps, 

K., in Mr. E/s house, had mnmps on April 27, 1880, and was placed 
in the sanatoriam. D. {Case 59), in the same house, had mumps on 
May 16, nineteen days after K. was isolated. G. {Case 60), in a different 
house, who sits two yards from K. in form, had mumps on May 14, 
seventeen days after K. was isolated. 

A., in Mr. B.'s house, had mumps on February 15, 1880, and was 
removed to the sanatorium. B. {Case 61), also in Mr. B.'s house, had . 
mumps on Murch 4, eighteen days after A* wau isolated. 

G., in Mr. S.'s house, had mumps on November 17, 1884, and was 
removed to the sanatorium on November 18. The following cases 
followed in this house : 

K. {Case 62) sickened on December 2, 15 days after G, began. 

M. (Cow 63) „ „ 5,18 „ 

E.3(C(Me64) „ „ 5,18 „ „ Sits next 

B. at breakfast and tea; 

(parotitis on December 7). 
E.1 {Case 65) „ „ 6, 19 dajs after G. began. Worked 

in same study as G. 
K. maj. {Case QQ) „ „ 7, 20 dajrs after G, began. Was in 

sick-room with G. just before 

he was isolated on 18th. 
M. B. {Case 67) „ „ 7, 20 days after G. began. Much 

withG. 
B. {Case 68) „ „ 7, 20 days after G. began. 

S. (C(we69) „ „ 8,21 „ „ G. often 

in his study. 
K. min. {Case 70) „ „ 11, 24 days after G. began. Sat next 

G. at preparation. 

One other case (^Case 71) occurred in another house, viz. W., in 
Mr. M.'s house, on December 6, nineteen days after G. began. 

A. had mumps on March 9, 1885, and was removed to sanatorium. 
B. {Case 72), who resided in another house, but met A. in class, had 
mumps on March 30, twenty-one days after A. was isolated, and G. 
{Case 73), who also resided in another house, but sat behind A. in 
chapel, had mumps on March 31, twenty-two days after A. was isolated. 

B.j, in Mr. B. S.'s house, had mum^s on February 2, 1888, and was 
removed to the sanatorium. The following cases followed in this house : 

B.j {Case 74) had mumps on February 19, 17 days after B., was isolated. 

In same form and sat 

next but one at meals. 
O. {Case 75) „ „ 19, 17 days after B.j was isolated. 

In same dormitory with 

B.|. 
N. {Case 76) ,, „ 19, 17 days after B.^ was isolated. 

In same dormitory with 

B.|. 

B. S. (Ca«e77) „ „ 22, 20 days after B.^ was isolated. 

Sits at same table with 
• B.J. 
G. {Case 78) „ „ 23, 21 days after B.^ was isolated. 

B.(C(we79) „ „ 24,22 

C. Ca«e80) „ „ 24,22 „ „ 



Mumps, 117 

Cases 81 atid 82. 

Communicated by Dr. F« Adams Clabkb* 

Two children, girls {Cases 81 and 82), admitted to St. Pancras 
Schools^ at Leavesden, on January 4, were examined then and found 
apparently healthy. They were, according to custom, quarantined for 
twenty oone days along with other children admitted on that day, and 
during this period could not have come into contact with mumps. On 
January 24 they were again examined and were apparently quite well, 
and on January 25 they psissed into the body of tiie school. On 
January 28 both the children developed mumps, twenty -four days after 
leaving London for school. 

Cases 83 io 86. 
Communicated by Dr. C. W. HAict Bbowk. 

The boys returned to a public school on January 24. On January 27 
S., who had felt quite well on the previous day, complained of pain and 
swelling in the right parotid. D., F., W., and K. had been in class with 
him on January 26, but did not see him after 12.30 p.m. on that day. 
These four boys — D., P., W., K. — boarded in four different houses, and 
no one of them in the same house as S. They sickened as follows : 

On February 14, D. (Case 83) complained of pain in right parotid at 
6 p.m., and had swelling and fever next morning. 

On February 15, F (Case 84) complained of swelling in right parotid 
at 3 p.m., having feltpain there for twelve hours. 

On February 17, W. (Case 85) and K. (Case 86), had well-developed 
mumps. They had felt ill since the morning of February 16, but had not 
complained. Mumps developed in these cases on the following days : — 

D. F. W. K. 

20 21 23 23 after January 26, when exposure ceased. 
22 23 25 25 „ 24, „ began. 

Case 87. 
Communicated by Dr. Catlbt. 

Walter C, aged 14, returned home to Clifton from Marlborough 
College, where there was an epidemic of mumps, on April 8, 1878. 
On AprQ 16 he was attacked by mumps, eight days after cessation of 
exposure to infection. 

Case 88. 
Communicated by Dr. F. Pbabse. 

The day before beginning to suffer from an attack of scarlet fever» 
and while feeling ill, the reporter visited a case of mumps. While 
convalescing from scarlet fever, and exactly eighteen days after the 
single visit to the case of mumps, he developed the first symptoms of 
mumps. 

Cases 89 to 91. 

Communicated by Dr. G. BiBT. 

A boy, F. G., aged 11, had a swollen face on May 17 ; he was first 
seen on May 18, when he had well-developed mumps, and was isolated 



118 rMttmps. 

on that day. The following cases subsequently occurred in this 
family : 

W. G. (Case 89), male, aged 19, showed mumps on June 1, thirteen 
days after isolation of F. G. 

A. G. (Case 90), male, aged 13, showed mumps on June 2, fourteen 
days after isolation of F. G. 

B. G. {Case 91), female, aged 17, showed mumps on June 5, seven- 
teen days after isolation of F. G. 

Cases 92 io 97. 
Communicated by Dr. B. Duke. 

On December 6, 1885, two members of the same family failed with 
mumps. Three other cases occurred in the family. Two (Cases 92 and 
93) fi^ed on December 24, and one (Case 94) on December 25, eighteen 
and nineteen days after December 6. 

On December 9 a case of mumps occurred in a family. Three other 
cases (Cases 95 to 97) subsequently occurred in the same family, falling 
ill on December 25, 27, and 30 respectively (sixteen, eighteen, and 
twenty-one days respectively after the first case began). 

Cases 98 to 120. 

Communicated by Dr. A. Stedmak. 

Epidemic at St. John's Schools. The boys returned to school on 
September 14, 1887. The first case of mumps occuiTed on October 4, 
twenty days after. The second case occurred on October 18, fourteen 
days later. All the cases connected with the case on October 4 are 
shown in the following table, the numbers being the number of days 
after October 4 : 





, . 




18 










16 




18 










16 


17 


18 


19 








16 


17 


18 


19 








16 


17 


18 


19 




21 


14 


16 


17 


18 


19 


20 


21 


Case 98. 


Cases 99 


Cases 103 


Cases 108 


Cases 114 


Case 118. 


Cases 119 




to 103. 


to 107. 


to lis. 


to 117. 


/ 


and ISO. 



Communicated by Dr. Chofinbt, M^decin-Major, 83rd Reg. d'Inf., St. Gaudens, 

Haute Garonne. 

In December, 1886, a small epidemic of mumps broke out in the 
garrison, of St. Gaudens (Haute Graronne). It was strictly limited to 

' the soldiers occupying four rooms in the barracks, two rooms on the 
second floor and two on the third. The first five cases occurred one 
after another in the same room, and in men occupying adjoining beds. 
The epidemic ceased in February, 1887. In May, 1888, a fresh epidemic 
broke out ; it began in the same rooms as had furnished the cases in 
the earlier epidemic ; seventeen men altogether were attacked during 
May, June, and July (when the attack ceased). The first eleven cases 
occurred in the four Iroomsi above mentioned, and of the remaining six, 
four occurred in these rooms also. A single case occurred in December, 

' 1888, also in one of these four rooms. 



Mumps, 119 

Cases 121 to 136. 
Commnnicated by Dr. W. Squibb. 

A girl, aged 8 {Case 121), and a boj, aged 6} {Case 122), were exposed 
to infection on April 9. The girl had swelling of the parotid on 
April 23, the boy on A^ril 25, foarteen and sixt^n days respectively 
after the exposure. {Temperature Observations on Child/ren in Health 
<and Disease, London, 1887.) 
. A boy, a^ed 12 {Case 123, see Measles, Case 111), had measles-rasli 
on March 30, ten days after leaving school. He had mumps on April 9, 
twenty days after leaving school. This boy was taken on March 30 to 
-a, house in which there were four children; these children {Cases 124 to 
127) all had mumps from April 23 to 25. Here the interval between 
the appearance of mumps in the boy and the first of the four subse- 
•quent cases was fourteen days. 

A boy, aged 8, attending a day school, who had not seemed very well 
for a week, had a stiff neck on March 20, 1870, and next day was 
febrile, and had parotitis. His next youngest brother and the nurse 
(Cases 128 cmd 129) had mumps on April 8 (nineteen days). Two 
sisters {Cases 130 and 131) sickened on April 9 and 10; the mother 
{Case 132) on April 12, and an infant, aged 1 year {Case 133), was 
febrile on April 12, and had enlarged parotid and submaxillary glands, 
with a temperature of 104' 7° at night on April 14. 

A boy was sent home on March 11, and was found to have mumps 
on the next day. A brother {Case 134) and a sister {Case 135) were 
separated from him on March 13, and sent away to different houses on 
March 14. The girl had stiff neck on March 25, and obvious mumps 
the next day — thirteen days after the separation. The boy was not 
well on April 2, was sent home on April 3, and had both parotids 
«wollen on the next day, twenty-two days after the separation and 
twenty-one after leaving home. 

A boy, aged 15 {Case 136), who had been associated at school with a 
fichool-fellow who "began with mumps" on December 16, returned 
home on December 17, where he was associated with five children. He 
left home on December 28, and on December 30 he had swelling of the 
right parotid. This was the first distinct symptom of mumps, though 
he had vomited on December 25, and had not looked well for the next 
few days. After a fortnight he returned home, but none of the five 
•children took the disease. 

(The above cases — 123 to 136 — are published in Dr. Squire's Preven- 
iion of Infective Fevers, London, 1887). 

A. H., aged 15 {Case 137), at a public school, had mumps (face 
swelled) on March 12, during an epidemic at the school. He had 
metastasis on March 28, and Was sent home a week later, three weeks 
after the mumps had begujx; he was febrile, and had ulceration of the 
orifice of the upper salivary gland ; yet a sister, older, and a brother, 
jounger than himself did not contract the disease. 



EUBEOLA. 

IN German measles^ as in measles^ the attempt to calculate 
the length of the true period of incubation is often ren- 
dered uncertain by the occurrence of a primary or prodromal 
stage of very uncertain duration. In some cases the appearance 
of the rash is preceded by coryza, malaise, or actual fever 
lasting one, two, or three days or even longer (six, or ? seven 
days) ; in others these symptoms are either absent, or sa 
slight as to escape observation. In calculating the latent 
period, therefore, it has been necessary to take the date of the 
appearance of the rash as the only available fixed date. 

Incubation Period* 

The number of cases received by the committee in which 
the disease is believed to have been contracted by a single 
short exposure to infection is small. They show so great a 
variation that a suspicion will at once arise that in the case 
of those which depart most widely from the average there 
may have been some exposure other than that to which in* 
f ection was attributed. 



Table I* — Showing cases in which exposure was briefs 





Interval between 


exposure 


and 


No. of case. 


First Bjmptom. 










Bash. 


78 


3 




5 


108 


>• "— 




5 


75 


4 -^ 




8 


85 


,» — 




11 


79 


I* — 




14 


77 


11 




16 


57 


>• ~~ . 




18 


58 


,. — 




18 


59 


,, — 




18 


76 


11 




18 


60 


,, — 




20 



Buheola. 12 1 

In four of the above ten cases the interval between the 
exposure and the appearance of the rash was eighteen days^ 
and in six it was sixteen to twenty days. These cases^ as far 
as they go, would tend to prove that the commonest date for 
the appearance of the rash was in the later part of the third 
week after exposure. Cases 85 and 79, however, show that 
the interval may be notably shorter, and in two of the cases 
with a longer period prodromal symptoms were noticed as 
early as the eleventh day. 

Cases have been reported by Dr. Bristowe (108) and by 
Drs. Willcocks and Carpenter (75 and 78) in which the 
period of incubation is assumed to have been very much 
shorter, namely in one eight days from exposure to rash, 
and in two five days from exposure to rash. In the caso 
with the longer period there were no prodromal symptoms^ 
but in one of the others these lasted two days, so that the 
report requires us to assume that the true incubation period 
in this case was only three days. This patient was a nurse 
in a hospital in which a small epidemic affecting the staff 
was in progress ; it seems far from impossible that she may 
have been infected by an earlier sufferer while he was in the 
prodromal stage. The other patient who sickened five days 
after exposure was also resident in a hospital. He was a 
youiig man who had never seen a case of German measles- 
before, that is to say, wittingly. It is impossible therefore, 
to assert that either of these patients may not have been 
exposed to infection at some date earlier than that assigned; 
at the same time it ought to be added that there is no evi* 
dence in either case of any such exposure, and that some 
writers have put the incubation period of this disease at 
about a week."^ Dr. Haig Brown, in the tabular statement 
which will be found at the end of the list of cases, states that 
a period of only six days was observed in 7 out of 75 cases 
in which it could be " computed fairly accurately,** while in 
S more it was only seven days; in 31 altogether,' it was ten 
days or less. On the other hand, in the statistics furnished 
by Dr. Clement Dukes from Rugby School, by Dr. Armstrongs 

* Dr. P^e-Smith states that the shortest period ohserved dnring an epidemic 
at Gny's Hospital in 1888 was eight days. Eustace Smith (DheMe* in Children) 
writes that " the stage of incubation may last from one to three weeks." Louis. 
Guinon, the author of the articles on the eruptive feyers in the TraUS de MSde" 
cine, now (1892) in course of publication, writes : — " La rub^ole est certainement 
celle des filrres ^ruptives dont la periode d'incnbation est le plus mal connue." 
He adds that authority may be found for all dates from 6 to 22 days, and that^ 
MM. BoumeTille and Bricon give 8 to 10 days. 



122 Rubeola. 

irom Wellington College, and by Dr. Stedman from St. 
John's Schools, Leatherhead, of school epidemics no such 
jshort periods appear. In all these cases, 69 in jiamber, the 
infector was isolated as soon as the rash was perceived, bat 
was associated with the boys infected down to that time ; the 
period given is that from rash to rash, and assuming that the 
disease is infectious from the commencement of the primary 
stage, as is probably the case, this interval would coincide 
approximately with the true incubation stage. The shortest 
interval recorded by Dr. Clement Dukes is nine days, by 
Dr. Armstrong eleven days, and by Dr. Stedman twelve days. 
The relative frequency with which the rash appears on each 
day in this series of 69 cases is shown in the following table : 

Table II. — Showing the interval between cessation of exposure 
and appearance of rash ('' rash to rash *') in 69 cases occur- 
ring in certain school epidemics^ 















96 
























95 
























94 
























48 
























47 






















69 


44 
















93 




73 


68 


48 




105 












71 




«6 


67 


88 




104 












63 




65 


52 


35 




103 












62 




29 


82 


34 


98 


102 












61 




25 


81 


33 


97 


101 












54 


72 


17 


30 


21 


50 


100 












40 


64 


16 


8 


20 


49 


99 












11 


28 


5 


7 


19 


46 


74 


41 




107 


56 


70 


8 


23 


4 


6 


18 


45 


89 


36 


13 


106 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


A 


9 10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 



It appears, therefore, that even if we confine our attenr 
tion to this series of cases, which does not show any excep- 
tional periods, it will be necessary to admit that the incuba- 
tion period varies very considerably, and that the rash is as 
likely to appear on the twelfth or fourteenth day as on the 
eighteenth. , They, however, do lead to the conclusion that 
the period from the twelfth to the eighteenth day is that during 
which the rash is most likely to make its appearance. In 
more than half the cases in the above table the rash was 
first noticed on one of the first three days of the third weekj 
After the cessation of exposure. 



Rubeola. 12^ 

r '  • . f» If.. 

Duration op Infectious Period. 

The cases given below prove very conclusively that 
rubeola is infectious duriug the very earliest stage^ resembling 
measles in this as in eo many other points. Gases 57 to 60 
reported by Dr. Railton are examples of infection derived 
from a child in whom the rash was just appearing; Case 77 
is an example of a similar occurrence. In Cases 75 and 85 
the exposure took place a short time before the appearance 
of the rash. The evidence of all the school cases is in the 
same, direction ; Dr. Clement Dukes* statement as to his ex- 
perience at Rugby is very explicit — [^ Isolate as soon as you 
will, even on mere suspicion, without waiting for evidence, 
it will spread.*' 

A patient probably ceases to be infectious as the rash 
fades, the only case which would cast any doubt on this 
assertion is Case 78 ; here the infection was supposed to have 
been derived from a patient whose rash had disappeared ten 
days earlier ; as has already been pointed out, this case is 
exceptional in the short assigned duration of the incubation 
period; the concurrence of these two exceptional circum- 
stances cannot fail to increase the suspicion that in this case 
there was some other source of infection. 

In severe cases there may be, after the rash has dis- 
appeared, some roughness and branny desquamation of the 
skin ; it has not been proved that this desquamation is cap- 
able of conveying the infection, but analogy seems to suggest 
some extra caution in these cases. Dr. Clement Dukes* rule 
probably meets the case well — isolation for a fortnight, 
followed by disinfection. In mild cases, in which category 
the great majority would be comprised, isolation for a week, 
followed by a bath, and disinfection of clothes, is probably 
amply sufficient, as Dr. Dukes* experience shows. At the 
same time it should be said that there is no evidence that the 
infection can be retained in clothes ; and the absence of such 
•evidence, taken together with the fact that the suflEerer him- 
self soon ceases to be infective, is strong evidence that the 
infective principle does not long retain vitality outside the 
human body, at any rate under ordinary circumstances. 

Conclusions. 

(1) The incubation period of rubeola is, as a rule to which 
there are many exceptions, some period more than two and 



124 Rubeola, 

less than three weeks. Eighteen days is probably the nsnal 
period. In a considerable number of cases it is a day or 
two less than two weeks^ in a few it is only eight or nine 
days^ and it is possible that in a small number it may be as 
short as six or five. 

(2) A susceptible person who has been exposed to the 
infection of rubeola may not develop the disease for twenty- 
one days^ possibly even a day or two longer^ and therefore^ 
if it be desired to isolate such a person until all risk is passed^ 
the period of quarantine should be two days more than 
three weeks. 

(3) A patient who has contracted rubeola is capable of 
conveying the infection to others for two or three days before 
the rash has appeared^ and also while the rash is out; but 
this capabOity rapidly declines, and has probably disappeared 
in a week in mild cases, and by the time desquamation i& 
over in the more severe. 



Cam 1 to £6.* 
Commimicated by Dr. Clbubst Duxia, Hedical Officer to Bngby School, 



 piper in tbe Laneet, 1S81, toL i, 



126 



Jliiheolat 



No. of 


luitial 
of 


Sex. 


Age. 


D&te. 


B^sidence. 


FoBuble gooroe 
of 


No. of days '■ 


case. 


patient. 










infection. 


incubating. 


1 








1882 






\ 


37 


W. 


Male 


? 


Feb. 28 


Mr. J. B. 


Fresh 


Centre 


88 


G. 


ft 


15 


Mar. 16 


f» 


No. 1 


16 


39 


F. 


99 


15 


., 17 


9» 


»* 


18 


40 


J. 


$9 


15 


„ 28 


» 


No. 2 


12 


41 


B. 


>» 


15 


April 4 
1883 


Mr.W. 


No. 2 ox 3 


19 or 20 


42 


S. 


M 


? 


May 11 


Mr. H. 


Fresh 


Centre 


43 


0. 


99 


» 


„ 27 


99 


No. 6 


16 


44 


R. 


9* 


99 


,» 27 


Mr. L. W. 


' 99 


16 


45 


B. 


19 


»> 


,, 28 


Mr. B. S. 


M 


17 


46 


C. 


>» 


>» 


« 28 


Mr. H. 


» 


17 


47 


E. 


» 


99 


June 12 


Mr. L. W. 


No. 8 


16 


48 


D. 


>» 


» 


99 12 


>» 


*> 


16 


49 


C. 


f» 


9» 


„ 13 


Mr. S. 


No. 7 


17 


50 


H. 


>» 


» 


„ 13 
. 1887 


Mr. £. 


No. 8 


17 


51 


C. 


f> 


»t 


Mar. 4 


Mr. J. B. 


Fresh 


Centre 


52 


P. 


99 


» 


„ 19 


») 


No. 15 


15 


53 


0. 


99 


>» 


„ 7 


»> 


Fresh 


Centre 


54 


C. 


99 


*» 


« 19 


»» 


No. 17 


12 


65 


C. 


»> 


»> 


99 10 


» 


Fresh 


Centre 


56 


N. 


99 


>» 


„ 19 


»* 


No. 19 


9 



Remarks, 

Case 3 slept in bed next to Case 2. 

Case 4 and Case 2 were great friends. 

Case 5 and Case 2 were great friends, and were in the same studj 
as Case 3. 

Case 6 was in the same bedroom as Case 1 ; but tbe disease is so 
highly infectious he may have caught it by passing or speaking to 
Case 2 — then it would be the fifteenth day. 

Case 8 was in the same study as, and great friends with, Case 7. 

Case 11 was in the same bedroom as Vase 10, and great friends with 
Case 9. 

Case 13 and Case 11 were the only two at tbe time. 

Case 16 was in the next bed to Case 14. 

Case 17 was in the same study as Case 15. 

Case 12, brother to and in the same study as Case 14. 

Case 19 was in the same study as Case 16. 

Case 23 was in the same study as Case 22. 

Case 25 was in the next bed to Case 24. 

Case 38 saw Case 37 a few minutes prior to my removing him to 
hospital. 

Case 39 was in Case STs study with him on- Febmary 27, 1882. 

Case 40 intimate with Case 38. 



Rubeola. 127 

Case 41 was in the same form with Cases 38 and 39. 

Case 43 was in the same bedroom with Case 42. 

Cases 44 and 45 were in the same form with Case 42. 

Case 46 was in the same stud^ with Case 42. 

Case 47 sat near Case 44 at dinner. 

Case 48. was in same study with Case 44. 

Case 49 was in same form with Case 43. 

Case 50 was in same form with Case 44. 

Case 52 did his work with Case 51. 

Case 54 did his work with Case 53. 

Case 56 was working with Case 55 just before he was isolated. 

> 

Omitting the cases which were fresh centres, sixteen in nnmber,. 
and omittinfi^ also Oases 6, 7, 11, 28 to 36, and 41, in which the source of 
infection was doubtful, there remain twenty-seven cases in which it 
could be named. In these twenty-seven cases it appears that the- 
incubation period cannot have been less than — 

9 days in 1 case 



12 


t» 


3 cases 


13 


it 


1 case 


14 


tf 


5 cases 


15 


tt 


2 „ 


16 


ft 


9 „ 


17 


tt 


4 „ 


18 


tt 


1 case 


20 


9t 


1 .. 



If the cases excluded above on the ground that the source of inf ec* 
tion was doubtful be included in order to show the shortest periods 
possible in the various cases, as may fairly be done, then the following 
are the facts : 

The incubation cannot have been less than — 



9 days in 1 case 


12 „ 


4 cases 


13 „ 


2 „ 


14 „ 


6 „ 


15 „ 


7 „ 


16 „ 


12 „ 


17 „ 


4 „ 


18 „ 


1 case 


19 „ 


2 cases 


20 „ 


1 case 



40 

As to the period of infectiveness, Dr. Olement Dukes says : — " Isolate 
as soon as you will, even on mere suspicion, without waiting for evi- 
dence, it will spread." In mild cases he recommends the following 
course: — "After about three days in bed, followed by four days of 
fresh air, the patient is washed from head to foot with carbolic soap, 
his clothes are put through the disinfecting chamber, and he returns 
to school." In severe cases, however. Dr. Dukes notes that the '* rash 
is followed by roughness of the skin. After isolation for fourteen days 
he is thoroughly £sinfected and returns to school." 



128 Rubeola. 

CascB 57 io 60. 

CoBmnnicated bj Dr. T. C. BAiLTom, Xaiidiester. 

On December 31, 1888, a eirl with the rash of rdihein just ooming 
<mt upon her met four chil&en — ^A., B., C^ D. — amone others at a 
small tea-parhr. Dr. Bailton on Jannarj 19 saw A. and B. {Ccues 57 
and 58), who had not sfain met the girl shore mentioned, with the 
rash and sore throat well marked; in both cases the rash had appeared 
on the daj before (January 18, i.e. eighteen days after exposure). 
Dr. B. was informed that the rash came oat on G. {C<ue 59} on 
January 18, and on D. {Ccue 60) on January 20. With reference to 
the diagnosis. Dr. B. states that both A. and B. had had measles 
within the year previous, and that the only symptoms during the 
attack of rothehi were rash, slight reddening and swelling of the fauces 
and edges of eyelids, and a very little branny desquamation. 

Cases 61 to 74 

Commnnicated by Dr. H. G. Asmstbovo, Medical Officer of WeUington 

College. 

On March 9 a boy in Mr. X.'s house was found to haye Grerman 
measles, and was isolated. Fresh cases occurred in this house, namely, 
three {Cases 61 to 63) on March 21, one (Case 64) on March 22, two 
(Cases 65 and 66) <m March 23, and three (Cases 67 to 69) on March 24. 
Further, on March 12 a boy in Mr. T.'s house was found to have the 
same disease, and was isolated. Fresh cases occurred in this house, 
namely, one (Case 70) on March 23, one (Case 71) on March 24, one 
(Case 72) on March 26, and one (Case 73) on March 27. 

A case occurred at a third house on March 21, and on March 24 
four other cases occurred in yarious other houses. If the cases in 
Mr. X.'s house on March 21 and subsequent days were due to infection 
by the case of March 9 in that house, then the duration of incubation 
was — 

Not less than 12 days in 3 cases. 
„ 13 „ 1 case. 

„ 14 „ 2 cases. 

15 .. 3 



» **' » " jf 



If the cases occurring in Mr. T.'s house were infected by the case 
occurring on March 12, then the period of incubation was, in the four 
cases occurring in that house subsequently, not less than eleyen, 
twelye, thirteen., and fourteen days respectively. 

Cases continued to occur up to and on March 28, when the school 
broke up ; a large number of boys had the disease at home. One case 
(Case 74) was reported as having commenced on the eighteenth day. 

Cases 75 to 84.* 
Communicated by Drs. Fbedsbick Willoooes and Gbobgb Cabpektbb. 

On January 20 Dr. A. M. (Case 75) saw a patient, Nurse A., suffer- 
ing from malaise, who developed the rash of rotheln a few hours later. 
Dr. A. M. did not see the patient again. On January 28, without any 

• Published in Fraotitioner, 1887 (vol. zzziz), p. 188. 



Rubeola, 129 

definite prodromal symptoms, the rash came out on Dr. A. M., eight 
days from exposure to rash. 

A clinical assistant (Case 76) saw Nurse A. on January 21, when her 
rash was fully developed. He had headache February 1 (eleven days), 
was indisposed with aching in back and limbs, coryza, &c., up to 
February 8, when rash appeared on face (eighteen days from exposure 
to rash). 

Mr. A. L. (Case 77) sat with Dr. A. M. for three hours on 
January 28, when his rash was developing. On February 8 he had 
pain in back and hip, coryza on February 12, and rash on February 13 
(sixteen d^s from exposure to rash). 

Nurse !r. {Case 78) saw Case 75 on February 9 for a few minutes, 
when he was supposed to be quite convalescent and his rash had dis- 
appeared for ten days. Nurse P. had headache and suflFusion of eyes 
on February 12 and rash on February 14 (five days). Nurse P. was 
employed in the same hospital as Nurse A. and Case 76. Prodromal 
symptoms lasted for an unusually long period in Case 76, and some 
doubt may be felt whether Nurse P. may not have come into direct 
relation with Case 76 before the rash appeared, and while he was only 
suffering from indefinite symptoms — aching, anorexia, and slight 
catarrh. 

Nurse M. {Case 79) went home on February 14 in good health. Her 
trunks were packed by Nurse P., who had at that time coryza but no 
rash. Nurse M. had rash on February 28 (fourteen days after exposure). 

Case 80, sister of Nurse M. Rash appeared March 14 (fourteen 
days from rash to rash). 

Case 81, servant to above and in attendance on them. Bash on 
March 16 (sixteen days after rash in Case 79). 

Case 82, mother of 79 and 80. Bash on March 19 (nineteen days 
after rash in Case 79). 

Case 83, sister of 79 and 80. Bash on April 1 (thirteen days after 
rash in Case 82). 

Case 84, brother of 79, 80, and 83. Bash on April 19 (eighteen days 
after rash in Case 83). 

Cases 85 to 92, 
Communicated by Dr. W. Squibb.* 

Two children spent two or three hours on December 13 with a child 
who had the rash that evening. The elder (Case 85) became ill, and 
had the rash on December 24, eleven days after exposure. The 
younger {Case 86), who was not isolated from her sister, had a sore 
throat on January 3 and rash on January 4, eleven days after the rash 
came out on her sister. 

A girl who attended a boarding-school as a day pupil had some 
spots on March 30, she had rash next day, and did not return to school. 
On April 12 another sirl {Case 87) at the school had spots on her face 
(thirteen days) and uie rash on the following day. Two other girls 
{Cases 88 and 89) had spots on April 13 (fourteen days), one {Case 90) 
on April 14 (fifteen days), one {(fase 91) on April 15 (sixteen days), and 
one {Case 92) on April 16 (seventeen days). 

* These cases were published by Dr. Squire in his Prevention of Infective 
JPevere, London, 1887. 



130 



Rubeola. 



Cases 93 to 107. 

Oommnnicsted by Br. Abthvb Stsdmait, Medical Officer to St. John's Schools^ 

Leatherhead. 

The first two oases of an epidemio oeeurred on Jane 3, and the nerfc 
cases were noted on the following dates : 

1 case on June 15, 12 days after the first 2 cases {Case 93). 

3 cases „ 19, 16 „ „ (Cases 94 to 96). 

2 „ „ 20, 17 „ „ (Cases 97 and 98). 
7 „ „ 21. 18 „ „ (Cases 99 to 105). 

2 „ „ 23, 21 „ „ (Cases 106 and 107). 

Oases also occurred on June 26 and 28 and on Jul^ 3, 5, 9, but the 
source of infection in these is, obviously, doubtful, since there was a 
case in the school on June 15, thirteen days earlier. 



Case 108. 

Communicated by Dr. J. S. Bbibtowe, F.R.S. 

During an outbreak of German measles at Westminster School, 
Dr. Bristowe took a young medical man, X., at that time holding a 
resident appointment in St. Thomas's Hospital, to the school to see 
some of the cases. X. had never seen the disease before. Five days 
afterwards he was attacked with genuine but rather severe German 
measles. There were neither then nor afterwards any cases of this 
disease in or about the hospital. 



Communicated by Dr. C. W. Hai& Bbown, Medical Officer of Charterhouse 

School, Godalming. 

The period of incubation could be ** computed ffidrly accurately in 
75 cases " out of 202. 



In 7 cases it was 6 days. 
3 „ 7 

1 case „ 8 

10 cases „ 9 

„ 11 „ 10 

„ 18 ,. 11 



9f 

t9 
99 



» 



9* 



In 10 cases it was 12 days. 
6 „ 13 



11 
5 
2 
2 



U 
15 
16 
17 



SCARLET FEVER. 

THE opinions held by various writers as to the duration of 
the period of incubation in scarlet fever have been con- 
flicting. Dr. Murchison, in the paper on the subject of in- 
cubation to which reference has already so frequently been 
made, collected, from a score of authors, estimates ranging 
from one day to one month. The examination of the large 
number of cases received by the Committee will show that, 
while the evidence for the shorter of these periods is very 
strong, there is none of a trustworthy sort to support the 
opinion that the incubation period can be extended beyond a 
week, or at most eight days. 



Incubation Period. 

In Table I, have been collected the cases in which the 
disease followed at a known interval an exposure for a short 
time to a known source of infection. The Table contains 34 
cases, and in 28 of these the time of onset of the earliest sym- 
ptoms is stated. This interval was : 



In 10 cases 

6 „ 

5 «. 
3 „ 

1 case 

2 cases 
1 case 



ft 
f» 

99 
99 
99 



2 days or less. 

More than 2, but not more than 3 days. 

6 days. 

7 

8 



*> 



99 



More than half the cases, therefore, show an incubation 
period of three days or less, and only four a period of more 
than five days. For the discussion of the relative frequency 
of short as compared with long periods of incubation, how- 
ever, it will be proper to include the cases in which the date 
of the appearance of the rash only is given, since the true 
period of incubation in these cases must have been some 
period less than that which intervened between the exposure 



132 Scarlet Fever. 

and the appearance of the rash, if indeed in certain cases the 
two periods did not coincide, approximately. 
Adding these cases, it will be found that : 

2 cases were attacked during the first twenty-four hours* 
10 „ „ second „ 

7 „ „ third „ 

6 „ „ fourth ,. 
4 „ „ fifth „ 
2 „ ^y sixth y^ 

2 ,, „ seventh „ 
1 „ „ eighth „ 

In a large number of cases the date at which exposure to 
infection commenced is known, but the exposure continued 
until the onset of the disease in the person thus infected. 
Obviously cases of this kind do not possess any value for the 
determination of long periods of incubation, but they may 
afford evidence as to the occurrence of unusually short 
periods. An examination of Table II, in which the cases of 
this order have been brought together, will show a consider- 
able number of instances in which the period of incubation 
must have been short. It is difficult without understating 
the case for a short period of incubation, to give any nu- 
merical summary of this Table ; in many of the instances in 
which the period was six to eight days it is easy to see from 
a perusal of the reports that there may have been circum- 
stances which caused a postponement of infection for several 
days. Isolation, even though the patient is in the sanae 
house, is often effectual during the acute stage while the 
patient is confined to bed, but fails as soon as conyalescence 
sets in, when it becomes very difficult to keep apart children 
who reside in the same house and have been accustomed to 
unrestricted intercourse. The numerical summary of the 
cases is as follows : 

3 cases were attacked during the^r*^ twenty-four hours* 
13 „ „ second „ 

17 „ „ third „ 

12 „ „ fourth „ 

10 „ „ sixth „ 

7 ,, „ seventh „ 

4 yy ,j eighth „ 

If the cases in Table I and Table II be taken together^ 



Scarlet Fever. 138 

we have 106 cases in which the interval between the only 
exposure, or the commencement of exposure and the onset of 
the disease is known ; that is to say, in these cases the period 
of incubation, if the facts be accepted, cannot have exceeded 
the intervals named. The following summary shows the 
length of time, after the earliest or only exposure, at which 
the patients were attacked, or were found to be suffering 
from the early stage of scarlet-fever rash : 

5 cases were attacked during the first twenty-four hours. 

23 „ „ second „ 

24 „ „ third „ 
18 „ „ fourth 
10 „ „ fifth 
12 „ „ sixth 

9 „ „ seventh 



5 „ „ eighth 



if 
yf 



>^ 



The five cases in which the onset of the disease followed 
within twenty-four hours the commencement of exposure to in- 
fection are Cases 26, 31, and 91, and i, and ii, in Dr. Murchison^s 
list. Case 91 was a child admitted into a children's hospital 
for a scald of the back, and it was believed that all sources of 
infection outside the hospital, in which there had been, in 
the same ward, a case of scarlet fever rather more than a 
month earlier, had been excluded. In Case 31 it is no doubt 
difficult to feel absolute certainty that there had been no 
previous undiscovered communication between the two 
families, who were related. To the three other cases there 
does not appear to be any obvious objection. Taken as a 
whole, the cases will afford strong support to the opinion held 
by Trousseau and others, that the onset of scarlet fever may 
teke place within twenty-four hours of the exposure to in- 
fection.* 

* Trousseau's case is recorded by him in his CUnical Medicine (New Syden- 
ham Society's translation^ vol. ii, pp. 165, 166. There is a misprint of days for 
hours in the translation). An English girl, who had passed the winter at Pau, 
went to Paris with her father early in 1859. In Paris she met her elder sister, 
who had travelled direct from London, where scarlet fever was epidemic. This 
sister was seized with fever and sore throat when crossing the Channel, and 
arrived in Paris, seven or eight hours later, in the middle of a very serious attack 
of scarlet fever. The two sisters arrived at the Paris hotel almost at the same 
moment. The younger showed the first symptoms of a mild attack of scarlet 
fever in twenty-four hours. There were no cases in Pau. "This curious 
history," Trousseau observes, " proves that in scarlet fever the duration of the 
period of incubation is sometimes not more than twenty-four hours. I am, how- 



134 Scarlet Fever. 

While affording evidence of the occasional occurrence of 
a period of only twenty-four hours, the cases are, as will be 
seen, very far from indicating that this is an ordinary or 
frequent period. They tend to prove that some period 
between twenty-four and seventy-two hours is the most 
common incubation period of scarlet fever. 

To the 106 above mentioned may be added four case& 
contained in Table IV, in which the date at which the exposure 
to infection began is known. The 110 cases thus obtained 
have been arranged in Table III, which affords a diagrammatic 
representation of the relative frequency with which the onset 
of scarlet fever occurred in the series of cases, on each of the 
days from one to eight. Cases in which the exposure to in- 
fection was for a longer period have not been included, since 
they cannot throw any light on the period of incubation^ 
The general error in this table is to overstate the probable 
length of the incubation period, but even so it shows 
that two, three, and four days are the commonest intervals 
between the commencement of exposure to infection and the 
onset of symptoms. Table I, taken by itself, gives a result 
which corresponds very fairly with that shown by Table III^ 
but makes the commonest incubation period a little shorter, 
as might be expected a priori. Nor does this exhaust the 
evidence in favour of the opinion that the customary incuba- 
tion period of scarlet fever is something less than four days* 
Appeal may be made (1) to the remarkable epidemic on ship- 
board reported to Dr. Murchison by Dr. J. Hogarth Pringle 

ever, very far from believing that that is its ordinary duration.*' Thomas- 
(Ziemssen's Cyclopedia, vol. ii, p. 167, English translation) mentions a case 
reported by Russegger as an example of an incubation period of less than 
twenty -four hours. The facts, which are not fully given by Thomas, are 
as follows {(Est. m. Jb,, 1848, 63 Bd., p. 282):— An epidemic of scarlet 
fever started in Eitzhiibel in July ; it appeared in Jochberg towards the end of 
July. A child in Jochberg visited a child with scarlet fever at noon; it became 
hot that evening, and early next day scarlet fever appeared. The date of the 
case quoted is not g^ven, so that there is no certainty that it did not occur during^ 
the epidemic in Jochberg. Rehn's case (Jrhbch, /. Khde., 1869, p. 439), also 
quoted by Thomas, is very inconclusive ; he merely thinks it probable that the 
incubation period may have been twenty -four hours because the grandmother, 
who apparently carried the infection in her clothes, came into more intimate 
relation with the child about that time before the onset of symptoms, but she 
had been in the same house for twenty-four hours longer. The grandmother, who- 
had been nursing a scarlatinous patient at Stuttgart, returned to Hanau, where 
there was no scarlet fever, on April 29th, aud then came in contact with her 
grandchild, aged 4^. The grandmother slept with the children the night of April 
30th — May 1st. The child had shivering, headache, &c., on May 1st about mid- 
day, and the rash on May 2nd. '' Die incubation kann demnach hier hdchstena 
48 Stunden, wird aber wahrscheinlich kaum 24 Stunden betragen haben." 



Scarlet Fever. 185 

(see Cases xxv to liv* below) ; (2) to the epidemic at 
TJpwell, laconically described in the extract from the school 
log-book given by Dr. Page (see paragraph following the 
description of Cases 97 and 98) ; and (3) to the outbreak 
following the festival in honour of William III, described by 
Dr. Blaxall (page 163). In both of these last-mentioned epi- 
demics a large number of cases followed, within four or fiv^ 
days, occasions of public assembly at which many children 
were present. 

While it is desirable to ascertain the shortest, and the cus- 
tomary periods of incubation in scarlet fever, it is perhaps of 
more practical consequence to learn the maximum length of 
the period of incubation. Certain authors have supposed that 
the latent period may be extended to ten days, a fortnight, 
or even a month.t 

The evidence on this head which has been placed at the 
disposal of the Committee is to be derived from certain cases 
in Tables I, and IV ; they are, however, significantly few in 
number ; indeed, if seven days be accepted as the limit beyond 
which a case is to be considered exceptional, then only two 
cases — two cases, that is to say, out of a total of fifty-nine, will 
fall into this category. If the circumstances under which 
these cases occurred prove on examination to be of a kind to 
eliminate all sources of fallacy, it would of course be necessary 
to accept their evidence, since one positive observation of the 
kind would outweigh the negative evidence of other ob- 
servers ; on the other hand, if the evidence in these cases is 
not conclusive, the fact that they are exceptional in the 
assigned length of the period of incubation would strengthen 
any doubts which might be raised by other circumstances. The 
two cases are Cases 62 and 75 ; as to the latter it may be ob- 
served that the child was a patient in a children's hospital, and 
it is well known that in such institutions it is exceedingly 

* Roman numerals refer to Dr. Mnrcbison's cases. 

t The following are given by Murchison : — (1) Niemeyer (Text-hook qfFraC' 
tical Medicine, Amer. trans., 1869, toI. ii, p. 533), eight or nine days. (2) R. 
Williams {On Morbid Poisons, 1886) and W. Aitken, a few hours to ten days. 

(3) Reinhold (Ziemssen's Cyclopadia, Amer. trans., vol. ii, p. 169)» eleven days. 

(4) Bathurst Woodman (Lond, Med, Joum., Feb., 1865, p. 76), two to fourteen 
days. (5) BOning (Ziemssen, loc. cit.), fourteen days. (6) Copland (Med. Diet,, 
vol. ii, p. 354), one to twenty-five days. (7) Maton (Trans, Col, Fh^s,, vol. v, 
p. 149), twenty-six days ; but Murchison finds, on reference to the original paper, 
that it is "very doubtful" whether the cases were scarlet fever at all. (8) Most 
(&esch. des Sisharlachf., ii, 178), one month. To this list may be added Dr. 
Lewis Smith, who, in Pepper's System (vol. i, p. 493), gives a case which is held 
to point to a period of twelve days (but the patient remained in the same house 
as the person infected). 



l36 Scarlet Fever. 

difficult to ensure that the children are not infected by friends 
who come to visit them from homes in which infectious 
diseases are often present^ a fact apt to be concealed from 
the authorities of the hospital^ especiallj if subsequent events 
lead to special enquiries being made. The other case is very 
briefly related^ no dates are given^ and it is not stated that 
the case was observed by the reporter himself. In discuss- 
ing such cases two facts must be borne constantly in mind^ 
namely^ the ease with which the infective agent in scarlet 
fever can be preserved and carried in fomites, and the cir- 
cumstance that the disease is sometimes^ especially in adults^ 
of so mild and anomalous a character that the patients do not 
apply for medical treatment, or the nature of their illness is 
not recognised. 

It is interesting to note that Dr. Murchison considered a 
case recorded by Dr. Squire, in which no symptoms were ob- 
served, though looked for with care, until the eighth day 
after the child had been removed from the infected house, 
as '^ about the best instance of long incubation-period in 
scarlatina '^ with which he was acquainted. In a communica- 
tion, however, addressed to the Committee (under date April 
4, 1892) Dr. Squire writes with reference to this case : — " Sub- 
sequent experience has made me doubt this single instance 
of an eight days incubation of scarlet fever ; and there was 
communication between the infected house and the child in 
quarantine. The distance between the houses was not 
great, and things were sent from one to the other.'* This 
fully confirms Dr. Murchison's suspicion expressed in 1878, 
that in such cases some fallacy lurks. 

On the whole, therefore, it would seem that the large 
number of cases collected by the Committee do not afford 
any instances which prove that the latent period in scarlet 
fever ever exceeds seven days. 

The general conclusion is thus practically identical with 
that reached by Dr. Murchison, who wrote* with reference to 
the alleged occurrence of long periods of incubation : — " I may 
add that during many years it has been my practice to pro- 
nounce persons, who had been exposed to the infection of 
scarlet fever, safe after a quarantine of seven days, provided 
their clothing had been properly disinfected ; and that so far 
I have seen no reason to alter this rule.** To this should be 
added the further proviso that the throat should be examined 

* TVanscu^ions, loc. cit* 



Scarlet Fever. 137 

carefully, and that the existence of sore throat shonld be re- 
^rded with the greatest suspicion. 

Milk. 

The cases in which infection was derived from the inges- 
tion of contaminated milk form a very interesting group, 
which appear to be deserving of separate consideration. In 
Bome there is good reason to believe that we are in possession 
of all the facts necessary to enable us to ascertain the period 
of incubation with the utmost precision. The cases have been 
collected in Table V, which is divided into three parts, accord- 
ing as the ingestion of the milk in question took place on a 
single occasion only, began at a known date, or ceased at a 
known date. There are eleven cases in the first division, and 
it will be seen that in none did the interval between the inges- 
tion of the milk and the full development of the disease exceed 
five days, that in seven it did not exceed forty-eight hours, 
that in four it was about thirty-six hours, and that in two it 
was only thirty hours ; the true incubation period, that is the 
interval between the ingestion of the milk and the onset of 
the earliest signs of illness, did not in any case in which it 
was ascertained exceed two days. In nine cases the date at 
which the use of the contaminated milk was commenced is 
known ; in all of these (with the exception of one in which it 
was not noticed at all) the rash came out within four days, 
and in none could the true period of incubation have exceeded 
three days. In three cases the use of the milk ceased at a 
known date, and all the patients had scarlet fever within two 
days. 

It must be admitted, therefore, that these cases point to a 
short period of incubation; further, it will be seen from a 
perusal of the reports that the evidence they afford is a good 
deal more voluminous than would appear merely from an 
inspection of Table V. In a very large number of cases, 
though the precise dates could not be given, the limit of time 
within which all the cases traceable to a particular contami- 
nated milk occurred, could be stated. For instance, in the 
epidemic following the use of certain cream at a dinner-party 
{see below the reports by Sir George Buchanan and Dr. 
Murchison), all the eighteen cases (twelve of scarlet fever and 
six of sore throat) occurred between the second and the fifth 
days thereafter. In the Fallowfield outbreak (see below 
abstract of Dr. Airy's report, page 171) the last case of 



/ 



188 Scarlet Fever. 

scarlet fever occurred five days after the contaminatioii of 
the milk may have begun, and only three days after such, 
contamination was at its maximum. Two cases of sore throat 
occurred later, but the whole outbreak in its relation to tha 
milk supply was over seven days after the commencement of 
the specific pollution of the milk, and five after this was at its- 
maximum. The Wimbledon epidemic (see p. 173) also afEord& 
evidence of a striking kind as to the occurrence of short periods- 
of incubation, and also, though of a less conclusive character^ 
against the occurrence of long periods. The main epidemic 
was traced to the use of milk supplied by a particular dairy- 
man ; the sale of the milk was stopped, and within forty-eight 
hours the number of cases showed an immense decrease ; in 
all probability the epidemic was completely arrested so far a& 
it was due to his milk, but as cases had been occurring for 
five days before the sale was stopped, the mode of infection 
could not be traced with certainty in every instance. Thi& 
dairyman, when he was prevented from continuing the sal& 
of his milk, sold two of his cows to a neighbour, who com- 
bined with the trade of a butcher that of a milkseller. On 
the second day after this sale of the cows cases of scarlet fever 
began to occur among the butcher- milkman's customers, but 
the chief incidence on them was on the third day, when ten 
out of the total of twenty-four cases were attacked. 



Unrecognised cases. 

Reference has already been made to the occurrence of case& 
of so mild a character that the patients do not come under 
medical treatment, or so anomalous that the true nature of 
the disorder is not recognised. A most striking instance of 
this is the case of Dr. Murchison himself (Case 23). In. 
Case 65 infection was derived from a girl who was suffering 
from a sore throat, the specific nature of which was not recog- 
nised, though she had been staying in a house in which scarlet 
fever was prevalent. Dr. Page gives an account (see Cases 
99 and 100) of an epidemic started in a village by a young- 
man who was treated for "ulcerated sore throat.'^ Dr. 
Parson's report, an extract from which will be found at 
page 162, gives another instance of the occurrence of unre- 
cognised cases of scarlet fever supposed to be " simple sore 
throat." Examples of such confusion might easily be multi- 
plied, but instances are probably within the experience of 



Scarlet Fever. ISC' 

everyone. Dr. Squire has communicated a case in which a^ 
schoolboy who, when his school was broken up on account o£ 
scarlet fever, was allowed to return home, though he had a 
sore throat. His mother sickened with scarlet fever three 
days later, and other cases subsequently occurred in the 
family* 

Scarlet fever sometimes leaves a special liability to sore 
throat ; it would be important to ascertain whether, as seems- 
to be the case in diphtheria, patients suffering from these 
recurrent attacks of throat illness are capable of infecting 
others with scarlet fever. Dr. Squire gives one case in which 
this seems to have occurred, but the data at hand are too 
scanty to allow any conclusions to be drawn here. 

In the reports of epidemics due to drinking specifically pol- 
luted milk, it will be found that mention is made of cases of 
sore throat, and more rarely of severe diarrhoea, occurring" 
in relation with the infection of scarlet fever. It has been re- 
marked in some of these epidemics that there was remarkably 
little evidence of extension by personal intercourse, still there 
can be no doubt that these cases of sore throat which are 
produced by exposure to infection of scarlet fever are capable 
of producing the disease. As to the power to convey the infec- 
tion of scarlet fever of those anomalous cases in which diar- 
rhoea is the only symptom, the reports communicated to the- 
Committee do not afford any positive conclusions ; some such 
cases, which at first present only symptoms referable to the 
gastro-intestinal tract, subsequently develop a characteristic 
rash. It would seem, therefore, that the prudent course 
would be to regard all cases of severe diarrhoea and vomiting^ 
occurring in relation with cases of scarlet fever as possibly 
due to the same infection, and as calling for the same pre- 
cautions as to isolation and disinfection as those in which the^ 
rash is clearly developed. 

* Dr. Francis Bond has recorded a case {Brit. Med. Joum., 1S82, vol. ii». 
p. 560) which illustrates this point so well that it may be convenient to quote it 
here : — A lad, aged 17, who had had scarlet fever a year before, was sent home 
from a school where scarlet fever had broken out. He was not aUowed to enter 
the house until he had had a carbolic bath in an outhouse, and had put on old 
clothes sent from the house on purpose, and had been taken for a long walk. He- 
was then allowed to enter his father's house, taking with him absolutely nothing 
he had brought from school except a pocket-book. In a "few days" one of the- 
other children had scarlet fever, and the others all followed. Dr. Bond subse- 
quently ascertained that the boy had a sore throat a day or two before he was 
sent home, and on examining the throat~-n early three weeks afterwards — he 
detected traces of slight congestion there. Dr. Bond attributes the infection of 
the other children to the throat affection. 



140 Scarlet Fever. 

FomUes. 

Scarlet fever is easily^ and probably very frequently, 
carried by fomites. Examples of infection by clothes and 
other fomites are afforded by Cases 20, 21, 71, 72, 73, 101, 
102, 103, 104, iv, and the interesting series given by Dr. 
Marchison (xxv to liv). In the last-mentioned series, 
thirty cases occurred on shipboard within four days after 
some clothes which had been packed np three months before 
in an infected house were unpacked and taken into use. In 
the case of a woman who slept in a bed occupied on the 
previous night by a child suffering from the disease, the period 
of incubation was short, two days. In the four cases ob- 
served by Dr. Tonge-Smith, in which persons were infected 
by travelling in an ambulance used for transporting cases of 
43carlet fever, the period of incubation varied from two days 
and a half to three days." 

Though the fact that scarlet fever can be conveyed by 
fomites is well known, it is probable that it has not always 
been borne in mind by writers who have assigned unusually 
long periods of incubation. Hildenbrand is said to have 
caught scarlet fever from his own cloak, which, after expo- 
sure to the poison, had been locked up for eighteen months. 
''^It has been well remarked," says Dr. Murchison, *^that had 
he put on this cloak at the end of one, instead of at the end 
of eighteen months, after visiting the patient who infected 
the cloak, and been then attacked, the case would have been 
quoted as one proving the possibility of the incubation-period 
extending over four weeks." 

Dead bodies, — The infection can be caught by paying a 
visit to a house in which a patient has died in order to see 
the body. One such instance is quoted from Dr. Blaxall. 

Conveyance of infection by persons who did not suffer. 

The cases afford a few instances also of infection carried 
by persons who did not themselves suffer from the disease. 
In one case the carrier of the infection, after visiting a patient 
on the fourth day of the illness, while the rash was profuse 
{Case 26), walked across some fields and then came into close 
contact with a boy aged eight or nine, who began to be ill twenty- 
four hours afterwards. In another instance (Case 100) the in- 
fection appears to have been carried to an isolated farm- 
house by a young schoolmistress who went to reside there 



Scarlet Fever. 141 

-when the school in which she taught was closed on account 
of an epidemic. In two cases recorded by Dr. Murchison 
(Cases Ixxiii and Ixxiv) the disease seems to have been con- 
tracted through a girl who had visited an infected house but 
did not herself suffer from the disease. In a case reported 
by Dr. Parsons (Case 94) it is possible that infection was 
conveyed in a similar manner. 

It is probable that these cases are all essentially instances 
of conveyance of infection by fomites, but, as has been al- 
ready observed, an epidemic may be started by a person who 
after exposure to the infection of scarlet fever has suffered 
only from sore throat. 

DUEATION OF PbEIOD OF INFECTIOUSNESS. 

The cases in which infection was derived from a patient 
in an early stage have been brought together in Table VI. 
They are few in number, and in none is it necessary to sup- 
pose that the infection was caught until the patient was 
suffering from marked but perhaps indefinite symptoms of 
illness, or was within a few hours of showing the rash. Dr. 
Blaxall"^ mentions an epidemic in a village school, which was 
probably started by children who attended while in the in- 
cubation-stage, but these children did not leave until they 
were ^' ill with scarlatina.'* On the whole the cases support 
the opinion that while scarlet fever has an infecting power 
from the earliest stage of the malady, yet, to quote an 
additional argument from Dr. Murchison, t *^the comparative 
facility of preventing its spread in a school points to this 
power being much less during the first two or three days 
than in the case of measles.*' 

The contrast in the behaviour of these two diseases is con- 
tinued at the opposite extreme of their course, for a patient 
who has suffered from scarlet fever is infectious long after 
convalescence has been completely established. Cases bear- 
ing on this point are shown in Table VII. In some of these 
instances the theory that infection was due to fomites may be 
accepted without much hesitation ; but in others, in those, 
namely, in which the patients had been inmates, sometimes for 
as long as six or seven weeks, of well-appointed hospitals 
specially devoted to the treatment of infectious diseases, this 
hardly appears tenable. In one of Dr. Murchison's cases 

* See below, abstract of Beport on Scarlet Fever in Lower Brizham (p. 162). 
t Transaction*, loc. cit. 



142 Scarlet Fever, 

(xxiv) it would appear that the infection could not have been 
derived from fomites, and that the occurrence of a tardy de- 
squamation, after this process had already twice taken place^ 
was the source from which infection was derived. The 
longest period mentioned in any instance is in a very 
similar case (58). The infector was undergoing a second 
desquamation of the feet eight weeks after the beginning of 
her attack of scarlet fever. In the majority of the cases^ 
however, the condition of the convalescent person who in- 
fected others is not stated with sufficient precision or fulness 
to warrant us in drawing any conclusions as to the mode in 
^hich the infection was preserved for these long periods. In 
is, however, well shown that the mere efflux of time cannot 
be trusted, and that a patient who is completely convalescent — 
so far, at any rate, as would appear on a cursory examination — 
may yet be, in some way, capable of infecting others. The 
facts observed in some cases render it probable that a minute 
examination might in all have revealed some pathological 
condition which would have accounted for the persistence of 
infection. 



Scarlet Fevbb in relation with- the Pueeperal State, 

AND WITH Traumatism. 

The only cases throwing any light on the relation of 
scarlatina to the puerperal state are those communicated by 
Dr. Boxall, and already published by him elsewhere. They 
are of two orders : in the one the patient was exposed to in- 
fection during or immediately after labour ; in no one of these 
three cases can the period of incubation have exceeded 
seventy-two hours, and the author observes that it seems 
possible that when infection takes place during or shortly 
after labour, the incubation-period may be shortened. In 
the other set of cases the women had been exposed to, in 
some instances had been in close contact with, patients for 
various periods before delivery ; these women were attacked 
from two and a half to about five days after delivery, but 
from a month to a week after the beginning of exposure. In 
all the cases the exposure was continuous up to the time of 
the admission of the woman in labour into a lying-in hospital, 
and in two of the cases it appears to be impossible to come 
to any other conclusion than that labour in some way deter- 
mined the onset of scarlet fever, or rather was the determin- 



Scarlet Fever. 143 

ing cause that the woman took scarlet fever at all (Cases 138^ 
139). 

The cases illustrating the relation of scarlatina to trau- 
matism are also few in number, consisting only of those sent 
l)y Mr. Scott Battams, formerly Resident Medical Officer of 
the East London Hospital for Children, Shadwell. The cases 
are too few to warrant any conclusions being drawn from 
them, but it will be noticed that the cases of scald show very 
«hort periods of incubation. The two cases in which the 
•operation for cleft palate was performed appear to be examples 
of the influence of traumatism in determining the onset of 
rscarlet fever (see table appended to cases, page 161). 

Conclusions. 

(1) The incubation-period of scarlet fever is usually some 
3)eriod between twenty-four and seventy-two hours ; it is 
occasionally less than twenty-four hours, frequently more 
than the longer limit above mentioned. Periods of four, five, 
^nd six days are often to be met with, and of seven days 
occasionally, but it is very doubtful whether the period of 
incubation is ever extended to eight days. 

(2) Scarlet fever is infectious from the onset of the earliest 
symptoms, and until long after convalescence has been 
established. Infection certainly persists as long as there is 
Any desquamation, and may still be active eight weeks after 
the onset of the disease. 

(3) The infection of scarlet fever is readily preserved in 
:and conveyed by fomites. 

(4) The symptoms of scarlet fever may be very anomalous 
or very little marked, and, especially in the adult, may consist 
only of sore throat. . 

(5) A person who has been exposed to the infection of 
scarlet fever, if at the end of seven clear days he is free from 
fever and from sore throat, and does not show any signs of 
illness, may, after disinfection of his clothes and other fomites, 
be pronounced safe. 

(6) There is no proof that the period of incubation is 
shorter or longer in persons who have met with an injury, nor 
in women who have recently been delivered, but there are 
grounds for believing that the occurrence of labour or of 
traumatism may determine the onset of scarlet fever in 
persons who had previously been exposed to infection 
without taking the disease. 




5 -n^-**^  '^^ ■^J^'^K 



Scarlet Fever. 



145 



Table II. — Containing cases in which exposv/re began at a 
known date, showing interval between commencement of ex^ 
posv/re to infection and the onset of the disease. 





Tnterval from commencement 




No. of 


of exposure to 




VttoCs 


Yint 
symptoms. 


Rash. 




• 

1 


18 hours 


Less than 
36 hours 


Nursed a sister suffering from severe attack. 


• • 

11 


24 hours 


— 


Nursed a patient in early stage. 


91 




1 day 


Followed a scald of hack. 


iv 


30 hours 


^^ 


After operation; attended hy a nurse from a 
scarlet fever case. 


V 


36 hours 


-^ 


Went as servant to infected house. 


• • 

Vll 


» 


— 


Nursed her son* who had malignant scarlet fever. 


xiu (d) 


» 


- — 


? Pomites. 


89 


— 


2 days 


Followed a scald of chest. 


93 


— 


>» 


Followed scalds. 


42 


48 hours 




Admitted in error to a scarlet fever ward. 


xiv 


99 


— 


Infected hy convalescent brother. 


XV 


»t 


— 


Nurse in scarlet fever ward. 


xvi 


ft 


— 


Stayed in an infected hotel. 


63 


it 


54 hours 


Admitted in error to a scarlet fever ward. 


11 


>» 


60 hours 


Child infected by her nurse, who did not suffer. 


113 


2 days 


— 


Boy infected by convalescent sister. 


1 


52 hours 


60 hours 


Child infected by convalescent brother. 


• •• 

XVIU 


2^ days 


3 days 


Nursed a child "badly ill" with scarlet fever. 


107 


64 hours 


72 hours 


Admitted in error into scarlet fever ward. 


4 


69 hours 


_ 


Acted as sick nurse to her sister. 


108 


72 hours 


— 


Nurse in scarlet fever ward. 


106 


70 hours 


74 hours 


Admitted in error into scarlet fever ward. 


90 




3 days 


Followed bum of face. 


92 


._ 


»> 


Followed a bum or scald. 


2 


72 hours 


84 hours 


Child infected by convalescent sister. 


8 


» 


» 


Ditto. 


5 


99 




Boarder in school in which there had been scarlet 
fever recently. 


82 


3 days 


— 


Infected by convalescent patients. 


xix 


» 


4 days 


Returned to a school in which one child had 
scarlet fever. 


87 


*9 


99 


A patient suffering from ozoona and keratitis. 


88 


» 


» 


Was sounded for stone, day exposure began. 


96 


M 





Attended same school as convalescent children. 


117 


ft 


4 days 


Mother infected by son with unrecognised scarlet 
fever. 


xxi 


8|daj8 




Admitted to fever hospital for supposed typhus 
fever; attended by a nurse from scarlet fever 
ward. 


8 


90 hours 


92 hours 


Child infected by convalescent sister. 


109 


102 hours 


^— 


Ward servant in infectious hospital. 



144 



Scarlet Fever. 



Table I. — Cases in which there wa>s exposure for a short 

known period. 



No. 



26 

• • • 

111 
81 

57 

vi 
zi 

54 

• • 

Xll 

20 

24 
97 
life 
101 
104 
103 
102 
105 

XX 



94 
25 
58 
28 
80 
xxii 
98 
55 
Iv 
27 
10 
74 
29 

83 
21 
75 



Ajgt of 

person 

infected, 



8 or 9 
Child 



20 
11 
4i 

3 

. 30 

Adult 

8 
Child 
»* 



22 



Child 
Adult 

19 
Adult 

5 

4 
Adult 

2 
44 
Adult 

Child 
Adult 

8 
Adult 
Child 



Mode of infection. 



Mediate 

Visited a house in which was a patient . 

Visited a patient 

Visited a convalescing patient 

Visited a house in which there were patients 

Stood close to a patient for two hours . 

Played with a patient .... 
Contact for ten minutes • • 

Slept in hed occupied by a patient on previous 

night 
Played four hours with three patients 
Contact with patients or convalescents 
Personal communication 
Scarlet fever ambulance 



*» 






ft 



»> 



Contact with convalescents in a public con 

veyance 
Kissed a slight case . • • • 



Mediate 

Visited room in which patieuts were 
Slept with desquamatiug convalescent . 

Visited a patient 

Nursed by a patient with rash 

Played with a sickening child 

Personal contact with patients or convalescents 

Short contact with infected child . 

Contact with patient; food from infected house 

Visited house of convalescents 

Visited a patient; second attack • 

Contact with a patient; first day . 

Visited a patient with sore throat ; day be 

fore rash 
Contact with patient • • • • 

Clothes 

In next cot to patient ; first day . . 



Interval to 


First 
symptoms. 


Rash. 


24 hours 


30 hours 


26 to 80 


— 


hours 




1 day 


About 




30 hours 


— 


36 hours 


36 hours 


^— 


36 to 40 


48 hours 


hours 






2 days 


36 to 41 


60 hours 


hours 




Less than 


>9 


48 hours 




>f 


» 


2 days 





i» 


4 days 


60 hours 


— 


64 hours 


^m. 




72 hours 


72 hours 


— 


3 days 


3 days 




and a few 




hours 


76 hours 


84 hours 


— 


4 days 


4 days 


6 days 


>» 


t9 


»» 


f» 


>» 




— 


6 days 


4^ days 


5i days 


5 days 


— 


»> 


7 days 


— 


6 days 


6 days 


— 


7 days 


M^k» 


8 days 


9 days 



Scarlet Fever, 



145 



Table II. — Containing cases in which exposure began at a 
known date^ showing interval between commencement of eX" 
posv/re to infection and the onset of the disease. 




II 
91 

iv 



Vll 

xiii (d) 

89 

93 

42 

xiv 

XV 

xvi 

63 

11 
113 

1 

• •• 

XVIU 

107 

4 

108 

106 

90 

92 

2 

3 

5 

32 
xix 

87 

88 

95 

117 



8 
109 



Interval from commencemeiit 
of exposure to 



I'irat 
symptoms. 



18 hours 
24 hours 

30 hours 

36 hours 
»» 
» 

48 hours 
» 

9 
» 

2 days 
52 hours 
2| days 
64 hours 

69 hours 
72 hours 

70 hours 

72 hours 

9» 

3 days 
» 

»» 

*f 

31 days 



90 hours 
102 hours 



Rash. 



Less than 
36 hours 

1 day 



2 days 



9» 



54 hours 
60 hours 

60 hours 

3 days 

72 hours 



74 hours 
3 days 

» 

84 hours 

99 



4i days 



»> 



99 



4 days 



92 hours 



Nursed a sister suffering from severe attack. 

Nursed a patient in early stage. 

Followed a scald of hack. 

After operation; attended hy a nurse from a 

scarlet fever case. 
Went as servant to infected house. 
Nursed her son* who had malignant scarlet fever. 
? Fomites. 

Followed a scald of chest. 
Followed scalds. 

Admitted in error to a scarlet fever ward. 
Infected hy convalescent hrother. 
Nurse in scarlet fever ward. 
Stayed in an infected hotel. 
Admitted in error to a scarlet fever ward. 
Child infected by her nurse, who did not suffer. 
Boy infected by convalescent sister. 
Child infected by convalescent brother. 
Nursed a child "badly ill" with scarlet fever. 
Admitted in error into scarlet fever ward. 
Acted as sick nurse to her sister. 
Nurse in scarlet fever ward. 
Admitted in error into scarlet fever ward. 
Followed burn of face. 
Followed a bum or scald. 
Child infected by convalescent sister. 

Ditto. 
Boarder in school in which there had been scarlet 

fever recently. 
Infected by convalescent patients. 
Returned to a school in which one child had 

scarlet fever. 
A patient suffering from ozosna and keratitis. 
Was sounded for stone, day exposure began. 
Attended same school as convalescent children. 
Mother infected by son with unrecognised scarlet 

fever. 
Admitted to fever hospital for supposed typhus 

fever ; attended by a nurse from scarlet fever 

ward. 
Child infected by convalescent sister. 
Ward servant in infectious hospital. 



144 



Scarlet Fever. 



Table I. — Cases in which there wa^ exposure for a short 

knovm period. 





Af^eof 


No. 


person 




infected. 


26 


8 or 9 


• • • 

111 


Child 


81 


9 


57 


20 


vi 


11 


• 

Zl 


4i 


54 


3 


• • 

xu 


. 30 


20 


Adult 


24 


8 


97 


Child 


lib 


>» 


101 


— 


104 


— 


103 




102 


— 


105 


— 


XX 


22 


94 


Child 


25 


Adult 


58 


19 


28 


Adult 


80 


5 


•  

XXll 


4 


98 


Adult 


55 


2 


Iv 


44 


27 


Adult 


10 


ff 


74 


Child 


29 


Adult 


83 


8 


21 


Adult 


75 


Child 



Mode of infection. 



Mediate 

Visited a house in which was a patient • 



Visited a patient 



Visited a convalescing patient 

Visited a house in which there were patients 

Stood close to a patient for two hours . 

Played with a patient .... 
Contact for ten minutes 

Slept in bed occupied by a patient on previous 

night 
Played four hours with three patients 
Contact with patients or convalescents 
Personal communication 
Scarlet fever ambulance 



» 



»» 



>9 



ft 



>9 



»» 



Contact with convalescents in a public con 

veyance 
Kissed a slight case .... 



Mediate 

Visited room in which patients were 
Slept with desquamating convalescent . 

Visited a patient 

Nursed by a patient with- rash . • 

Played with a sickening child 

Personal contact with patients or convalescents 

Short contact with infected child . 

Contact with patient; food from infected house 

Visited house of convalescents • • 

Visited a patient ; second attack . 

Contact with a patient; first day . 

Visited a patient with sore throat ; day be 

fore rash 
Contact with patient • • • • 

Clothes 

In next cot to patient ; first day . . 



Interval to 



First 
symptoms. 



24 hours 

26 to 80 

hours 

1 day 



36 hours 

86 to 40 

hours 

86 to 41 

hours 
Less than 
48 hours 

99 

2 days 

•« 
60 hours 
64 hours 

72 hours 

3 days 



99 

76 hours 



4 days 

99 
9* 

4i\ days 

5 days 

6 days 

7 days 

99 

8 days 



Rash. 



30 hours 



About 
80 hours 
86 hours 

48 hours 

2 days 
60 hours 

» 
4 days 



72 hours 



3 days 
and a few 

hours 

84 hours 

4 days 

6 days 

w 

99 

5 days 
5iday8 

7 days 

6 days 



9 days 



Scarlet Fever. 



145 



Table II. — Oontaining cases in which exposure began at a 
hnown date^ showing interval between commencement of eX" 
posv/re to infection and the onset of the disease. 




II 

91 
iv 



Vll 

xiu (d) 

89 

93 

42 

xiv 

XV 

xvi 

63 

11 

113 

1 

• •• 

XVIU 

107 

4 

108 

106 

90 

92 

2 

3 

5 

82 
xix 

87 

88 

95 

117 

xxi 



8 
109 



Interval from commencement 
of exposure to 



rirst 
symptoms. 



18 hours 
24 hours 
30 hours 
36 hours 
>f 

48 hours 
* 

» 

f 

_> 

2 days 
52 hours 
2^ days 
64 hours 

69 hours 
72 hours 

70 hours 

72 hours 
>» 

3 days 

99 

tf 
99 
» 

8|days 



90 hours 
102 hours 



Rash. 



Less than 
36 hours 

1 day 



2 days 



M 



54 hours 
60 hours 

60 hours 

3 days 

72 hours 



74 hours 
3 days 

99 

84 hours 



4 days 



» 



M 



4 days 



92 hours 






Nursed a sister suffering from severe attack. 

Narsed a patient in early stage. 

Followed a scald of back. 

After operation; attended by a nurse from a 

scarlet fever case. 
Went as servant to infected house. 
Nursed her son* who had malignant scarlet fever. 
P Eomites. 

Followed a scald of chest. 
Followed scalds. 

Admitted in error to a scarlet fever ward. 
Infected by convalescent brother. 
Nurse in scarlet fever ward. 
Stayed in an infected hotel. 
Admitted in error to a scarlet fever ward. 
Child infected by her nurse, who did not suffer. 
Boy infected by convalescent sister. 
Child infected by convalescent brother. 
Nursed a child "badly ill" with scarlet fever. 
Admitted in error into scarlet fever ward. 
Acted as sick nurse to her sister. 
Nurse in scarlet fever ward. 
Admitted in error into scarlet fever ward. 
Followed burn of face. 
Followed a bum or scald. 
Child infected by convalescent sister. 

Ditto. 
Boarder in school in which there had been scarlet 

fever recently. 
Infected by convalescent patients. 
Returned to a school in which one child had 

scarlet fever. 
A patient suffering from ozoena and keratitis. 
Was sounded for stone, day exposure began. 
Attended same school as convalescent children. 
Mother infected by son with unrecognised scarlet 

fever. 
Admitted to fever hospital for supposed typhus 

fever; attended by a nurse from scarlet fever 

ward. 
Child infected by convalescent sister. 
Ward servant in infectious hospital. 



144 



Scarlet Fever. 



Table I. — Cases in which there was exposure for a short 

hnown period. 





Age of 




Interval to 


No 


nfklTKAn 


Mode of infection. 




A« Wt 


infected. 


First 
Bymptoms. 


Rash. 


26 


8 or 9 


Mediate 


24 hours 


30 hours 


• • • 

HI 


Child 


Visited a house in which was a patient . 


26 to 30 
hours 


— 


31 


9 


Visited a patient 


1 day 


About 
30 hours 


57 


20 


Visited a convalescing patient 


— 


36 hours 


vi 


11 


Visited a house in which there were patients 


36 hours 


— 


• 


4i 


Stood close to a patient for two hours . 


36 to 40 
hours 


48 hours 


54 


3 


Played with a patient 




2 days 


• • 

xu 


. 30 


Contact for ten minutes . . . . 


36 to 41 
hours 


60 hours 


20 


Adult 


Slept in bed occupied by a patient on previous 


Less than 


» 






night 


48 hours 




24 


8 


Played four hours with three patients . 


» 


>t 


97 


Child 


Contact with patients or convalescents . 


2 days 


— 


life 


n 


Personal communication . . • . 


•t 


4 days 


101 


— 


Scarlet fever ambulance . . . . 


60 hours 


•F 


104 


— 


»» »» . , . . 


64 hours 


~— 


103 


— 


» 9> • . • . 


— 


72 hours 


102 


— 


>» M . . • . 


72 hours 


— i 


105 


^"~ 


Contact with convalescents in a public con- 
veyance 


>» 


— 


XX 


22 


Kissed a slight case 


3 days 


3 days 

and a few 

hours 


94 


Child 


Mediate 


» 


— 


25 


Adult 


Visited room in which patients were 


76 hours 


84 hours 


58 


19 


Slept with desquamating convalescent . 


— 


4 days , 


28 


Adult 


Visited a patient 


4 days 


5 days 


30 


5 


Nursed by a patient with- rash 


99 


99 


•  

XXll 


4 


Played with a sickening child 


99 


99 


98 


Adult 


Personal contact with patients or convalescents 


99 




55 


2 


Short contact with infected child . 




6 days 


Iv 


44 


Contact with patient; food from infected house 


4^ days 


Sidays 


27 


Adult 


Visited house of convalescents 


5 days 


.— 


10 


» 


Visited a patient; second attack • 


M 


7 days 


74 


Child 


Contact with a patient; first day . 





6 days 


29 


Adult 


Visited a patient with sore throat ; day be- 
fore rash 


6 days 


- 


83 


8 


Contact with patient 


7 days 


— 


21 


Adult 


Clothes 


»y 


— i 


75 


Child 


In next cot to patient ; first day . . 


8 days 


9 days 



Scarlet Fever. 



145 



Table II. — Containing ca^es in which exposure began at a 
Tcnown date^ showing interval between commencement of eX" 
posv/re to infection and the onset of the disease. 




11 
91 
iv 



Vll 

xiii(D) 

89 

93 

42 

xiv 

XV 

xvi 

63 

11 

113 

1 

• •• 

XVlll 

107 

4 

108 

106 

90 

92 

2 

3 

5 

32 
xix 

87 

88 

95 

117 

xxi 



8 
109 



Intervid from commencement 
of exposure to 



Krst 
symptoms. 



18 hours 
24 hours 
30 hours 
36 hours 

» 

48 hours 

» 
» 

2 days 
52 hours 
2^ days 
64 hours 

69 hours 
72 hours 

70 hours 

72 hours 

3 days 

if 
»» 

tf 

SIdays 



90 hours 
102 hours 



Rash. 



Less than 
36 hours 

1 day 



2 days 



99 



54 hours 
60 hours 

60 hours 

3 days 

72 hours 



74 hours 
3 days 

84 hours 

9> 



4 days 



99 



» 



4 days 




92 hours 






Nursed a sister suffering from severe attack. 

Nursed a patient in early stage. 

Followed a scald of hack. 

After operation; attended by a nurse from a 

scarlet fever case. 
Went as servant to infected house. 
Nursed her son^ who had malignant scarlet fever. 
? Fomites. 

Followed a scald of chest. 
Followed scalds. 

Admitted in error to a scarlet fever ward. 
Infected by convalescent brother. 
Nurse in scarlet fever ward. 
Stayed in an infected hotel. 
Admitted in error to a scarlet fever ward. 
Child infected by her nurse, who did not suffer. 
Boy infected by convalescent sister. 
Child infected by convalescent brother. 
Nursed a child "badly ill" with scarlet fever. 
Admitted in error into scarlet fever ward. 
Acted as sick nurse to her sister. 
Nurse in scarlet fever ward. 
Admitted in error into scarlet fever ward. 
Followed bum of face. 
Followed a bum or scald. 
Child infected by convalescent sister. 

Ditto. 
Boarder in school in which there had been scarlet 

fever recently. 
Infected by convalescent patients. 
Returned to a school in which one child had 

scarlet fever. 
A patient suffering from ozosna and keratitis. 
Was sounded for stone, day exposure began. 
Attended same school as convalescent chQdren. 
Mother infected by son with unrecognised scarlet 

fever. 
Admitted to fever hospital for supposed typhus 

fever; attended by a nurse from scarlet fever 

ward. 
Child infected by convalescent sister. 
Ward servant in infectious hospital. 



144 



Scarlet Fever* 



Table I. — Cases in which there was exposure for a short 

known period. 



No. 



26 

• • • 

111 

81 

57 
vi 
zi 

54 

• • 

Xll 

20 

24 

115 
101 
104 
103 
102 
105 

XX 



94 
25 
58 
28 
80 
zxii 
98 
55 
Iv 
27 
10 
74 
29 

88 
21 
75 



Age of 

person 

infected. 



8 or 9 
Child 



20 
11 
4& 

3 

. 80 

Adult 

8 
Child 
»t 



22 



Child 
Adult 

19 
Adult 

5 

4 
Adult 

2 
44 
Adult 

Child 
Adult 

8 
Adult 
Child 



Mode of infection. 



Mediate • 

Visited a house in which was a patient • 



Visited a patient 



Visited a convalescing patient 

Visited a house in which there were patients 

Stood close to a patient for two hours . 

Played with a patient .... 
Contact for ten minutes 

Slept in hed occupied hy a patient on previous 

night 
Played four hours with three patients 
Contact with patients or convalescents 
Personal communication 
Scarlet fever amhulance 



** 
ft 
>* 



»» 



Contact with convalescents in a puhlic con 

veyance 
Kissed a slight case . . • • 



Mediate 

Visited room in which patients were • 
Slept with desquamating convalescent . 

Visited a patient 

Nursed hy a patient with- rash 

Played with a sickening child 

Personal contact with patients or convalescents 

Short contact with infected child . 

Contact with patient; food from infected house 

Visited house of convalescents . • 

Visited a patient ; second attack • 

Contact with a patient ; first day . 

Visited a patient with sore throat ; day he 

fore rash 
Contact with patient • • • • 

Clothes 

In next cot to patient ; first day . . 



Interval to 



First 
symptoms. 



24 hours 

26 to 30 

hours 

1 day 



36 hours 

36 to 40 

hours 

36 to 41 

hours 
Less than 
48 hours 

9f 

2 days 

•t 
60 hours 
64 hours 

72 hours 
>• 

3 days 



76 hours 



4 days 

99 
»> 
>f 

4idays 

5 days 
» 

6 days 

7 days 

8 days 



Rash. 



30 hours 



Ahout 
30 hours 
36 hours 

48 hours 

2 days 
60 hours 

M 

4 days 



72 hours 



3 days 
and a few 

hours 

84 hours 

4 days 

6 days 

99 

5 days 
5i days 

7 days 

6 days 



9 days 



Scarlet Fever. 



145 



Table II. — Containing cases in which exposv/re began at a 
hnown date, showing interval between commencement of ea?- 
posure to infection and the onset of the disease. 




II 

91 
iv 



Vll 

xiii(D) 

89 

93 

42 

xiv 

XV 

xvi 

63 

11 

113 

1 

• •• 

XVIU 

107 

4 

108 

106 

90 

92 

2 

3 

5 

32 
xix 

87 

88 

96 

117 

zxi 



8 
109 



Interval from commencement 
of exposure to 



First 
symptoms. 



18 hours 
24 hours 
30 honrs 
36 hours 

9> 
>» 

48 hours 
>» 

>y 
»» 

2 days 
52 hours 

2^ days 
64 hours 

69 hours 
72 hours 

70 hours 

72 hours 

99 

3 days 
» 

»> 

9* 
>> 

»» 

3idays 

90 hours 
102 hours 



Bash. 



Less than 
36 hours 

Iday 



2 days 



»» 



54 hours 
60 hours 

60 hours 

3 days 

72 hours 



74 hours 
3 days 

»> 

84 hours 



4 days 



» 



»> 



4 days 



92 hours 






Nursed a sister suffering frotn severe attack. 

Nursed a patient in early stage. 

Followed a scald of hack. 

After operation; attended hy a nurse from a 

scarlet fever case. 
Went as servant to infected house. 
Nursed her sod» who had malignant scarlet fever. 
? Fomites. 

Followed a scald of chest. 
Followed scalds. 

Admitted in error to a scarlet fever ward. 
Infected hy convalescent brother. 
Nurse in scarlet fever ward. 
Stayed in an infected hotel. 
Admitted in error to a scarlet fever ward. 
Child infected by her nurse, who did not suffer. 
Boy infected by convalescent sister. 
Child infected by convalescent brother. 
Nursed a child "badly ill" with scarlet fever. 
Admitted in error into scarlet fever ward. 
Acted as sick nurse to her sister. 
Nurse in scarlet fever ward. 
Admitted in error into scarlet fever ward. 
Followed bum of face. 
Followed a bum or scald. 
Child infected by convalescent sister. 

Ditto. 
Boarder in school in which there had been scariet 

fever recently. 
Infected by convalescent patients. 
Returned to a school in which one child had 

scarlet fever. 
A patient suffering from ozoena and keratitis. 
Was sounded for stone, day exposure began. 
Attended same school as convalescent children. 
Mother infected by son with unrecognised scarlet 

fever. 
Admitted to fever hospital for supposed typhus 

fever; attended by a nurse from scarlet fever 

ward. 
Child infected by convalescent sister. 
Ward servant in infectious hospital. 



154 Scarlet Fever. 

scarlatinal rasli ; " tlie butcher's wife did not take scarlet fever at this 
time, but she had had scarlet fever in her youth. 

Cases 22 to 25. 
Communicated by Dr. B. Bozall, London. 

A mother, who began with scarlet fever on April 29, and her infant,, 
who had scarlet fever seventeen days later, were discharged from Stock- 
well Fever Hospital on Jane 15, and returned home that day. On 
June 17 one of her two other children {Case 22) went to Oxford, where^ 
so far as could be ascertained, there was no scarlet fever at the time,, 
and on June 20 (five days after her mother's return from Stockwell 
Hospital, and three after she herself left home) she was taken ill with 
scarlet fever ; the other child {Case 23) was taken ill with scarlet fever 
on June 21 (six days after her mother's return). It was " practicallj 
certain " that the mother took the infection in the lying-in hospital 
in which she was confined. 

A girl, aged 8 {Case 24), played, on Friday afternoon (2 — 6 p.m.), 
with the children of the head master of a large school. Three of these 
children were at the time suffering from mild scarlet fever; they had a 
rash, but the nature of their illness was at that time unrecognised.. 
On the following Sunday evening (forty-eight hours after playing with 
the master's children), Case 24 began to feel ill, and on the next morn- 
ing had well-developed scarlet fever. There was subsequently an 
epidemic in the schooL 

Reporter {Case 25), when Obstetric Assistant at University College 
Hospital, visited a woman recently confined, who had three children in 
bed together ill with what ultimately proved to be scarlet fever, on 
a Monday at 1 p.m. He did not see her again. On Thursday, about 
5 P.M. (seventy-six hours after the visit on Monday), he " was taken ill 
with violent sore throat," and on the " next day there was no doubt as- 
to the nature of the case." There was a good deal of scarlet fever in 
the neighbourhood at the time, and Dr. B. subsequently ascertained 
that at another house which he visited a week or ten days before, the 
door was opened to him by a boy who had the disease. 

Case 26. 
Communicated by Dr. Batolippb-Gaylabd. 

G. D. visited X., a man suffering from scarlet fever, on the fourth 
day of the illness, while the rash was profuse, and sat with him for ten 
minutes. 0. D. walked across some fields about a mile, and then called 
on a friend. One of the friend's boys, A. B., aged 8 or 9, stood close to 
G. D., within the embrace of his arm and in contact with his coat. 
A. B. complained of sore throat twenty-four hours after, and within 
thirty hours had high temperature and rash ; the disease subsequently 
ran the usual course. X. in all probability contracted the disease from 
his daughter, who was convalescent from scarlet fever when he sickened.. 
X., his child, and A. B. were the only cases of scarlet fever known in 
the neighbourhood. A. B. did not attend the same school as the othei" 
child, and had never come in contact with X. or his daughter. A. B. 
a few weeks previously had had measles, and the reporter suggests that 
*' this may account for his extreme susceptibility." G. D. was an adult 
who had had scarlet fever several years oefore ; the time between hi& 



Scarlet Fever. 135 

leaving X. and coming into actual contact with A. B. was about fortjr 
or sixty minutes. 

Case 27. 

Communicated by Dr. J. H. Spbkobb, Holbeach. 

^ A young lady who had been from home for two months, and had 
neither heard of nor seen any cases of scarlet fever, on her return home 
called at a house where the children had had scarlet fever, but had 
been convalescent and about for six weeks. She was attacked by scarlet 
fever five days later, and died in a week. 

Case 28. 

Communicated by Dr. T. F. Pbabsb. 

M. D. saw a case of scarlet fever on Monday afternoon. He had no 
other cases of scarlet fever in his practice, and did not see this case 
again. On Friday (about ninety-six hours after seeing the case) he 
felt ill, and on Saturday afternoon he showed the rash of scarlet fever. 

Cases 29 and 30. 
Communicated by Dr. P. W. Jolltb. 

A medical student returned home with a sore throat on Friday, and 
on Saturday had rash of scarlet fever. On Friday afternoon a young 
lady {Case 29) called at the house, and remained talking in the same 
room with the medical student. On the following Thursday evening 
the young lady complained of sore throat, and subsequently had a- 
rather severe attack of scarlet fever six days from exposure to sore 
throat. 

A servant girl was sent home by her employers as soon as she was 
found to have the rash of scarlet fever. Arrived at her home, an 
isolated house on the Wiltshire Downs, she nursed the youngest child, 
aged 5 {Case 30). After bein^ at home one and a half to two hours, she 
was removed to a fever hospital. Case 30, aged 5, had malaise four 
days afterwards, and the rash of scarlet fever on the next following 
day. 

Cases 31 to 33. 

Communicated by Dr. A. Hill, Medical Officer of Health, Birmingham. 

L. H. aged 9 {Case 31) visited a cousin who had scarlet fever on 
July 31 ; on August 1 she was taken ill with sore throat, sickness, and 
purging, and the eruption appeared the same evening. She waa 
admitted to hospital on August 2. From exposure to first symptoms, 
one day. 

Two sisters were discharged from the Birmingham City Infectious 
Hospital on the evening of August 3. A third sister, £. J. {Case 32), 
aged 5, sickened on August 6 ; eruption appeared on August 9. From 
return of convalescent sisters to first symptoms not more than three 
days. 

£. W. {Case 33), aged 7, was admitted to above hospital on Novem- 
ber 5, certified as having had scarlet fever, which, however, she had 



156 Scarlet Fever. 

not had. On November 17, twelve days after admission, she was taken 
ill with scarlet fever. 

Case 34. 

Commmnnicated by Dr. F. B. Htthphbby, Haverstock Hill. 

B., aged 17 months, who, in consequence of cases of scarlet fever 
being in her mother's house, had been at her grandmother's house in 
the neighbourhood, was taken home on December 19. On December 22 
fihe had " a cold in her eyes," on December 23 both tonsils were swollen, 
and on December 24 she had the rash of scarlet fever. Three days to 
8ore eyes, four days to tonsillitis, five days to rash. 

Cases 35 to 41. 
Communicated by Dr. Clement Duzes, Medical Officer to Bogby Scbool. 

M., aged 15, in Mr. Wh.'s house, Bugby School, had sore throat on 
November 7, rash on November 8, and was removed to hospital on the 
last named date. W., aged 16 {Case 35), in the same house, had sore 
throat on November 14, and rash on November 16. W.'s sore throat 
seven days after M.'s, and six days after M.'s isolation. 

J., in Mr. M.'s house, had sore throat on January 31, rash on Feb- 
ruary 1, and was removed to hospital on last named date. N. {Case 
36), who slept next him in dormitory, had sore throat on February 3 
and rash on February 4 ; N.'s sore throat three days after J.'s, and two 
days after J. was isolated. J., when convalescent on February 13, was 
placed in a room with a third boy who was in the early stage of a 
severe attack of scarlet fever. J. had tonsillitis on February 26, and 
had an eruption of scarlet fever again on March 1. 

P., in Mr. Wn.'s house, sickened with scarlet fever on March 21, 
and was sent to sanatorium. On. {Case 37), in same house, sickened on 
March 27, six days after P. was isolated. 

T., aged 12, sickened and was isolated on May 7. 0. {Case 38), aged 
10, in the same house, sickened on May 11, four days after T. was 
isolated. 

W., aged 17, sickened on February 21, and was isolated on that day. 
O. {Case 39), in the same house, who was working with W. the night 
before he was isolated, sickened on February 25, four days. B. J. {Vase 
48), in the same house as W., sickened on February 25, four days. 
H. {Ca>se 41), who was visited by W. in his study on February 21, and 
lived in the same house as W., also sickened on February 25. 

CoMs 42 to 51. 
Communicated by Dr. Mabe Fentok, Medical Officer of Health, Coventry. 

A. G. {Case 43), who had never had scarlet fever, entered the scarlet 
iever ward of the Oity Fever Hospital on December 27, in the evening. 
On December 29, forty-eight hours after exposure, the first symptom 
Appeared. A. G. had arrived at the hospital from the country on 
December 27. 

L. S., attJEusked with scarlet fever August 8, was discharged from the 
Fever Hospital on September 28, returned home, and immediately re- 
sumed association with sisters, one of whom, J. S. {Case 43), was attacked 
on October 6, eight days after return home of L. S. 

L. was discharged from the Fever Hospital on December 15, and re- 



Scarlet Fever. 157 

tamed home. Another child (Case 44) in the same family was attacked 
on December 22, seven days after return home of L. 

Sh. was discharged from the Fever Hospital on December 22. A 
second case (Case 45) appeared in the same family on January 1, ten 
days after return home of Sh. 

Si. was discharged from the Fever Hospital October 14. A second 
case {Case 46) occurred in this family on October 22, and a third case 
on October 23, eight and nine days respectively after return of Si. 

W. was discharged from the Fever Hospital on September 27. A 
second case {Case &) occurred in the same family on October 2, five 
days after the return of W. 

T. was discharged from the Fever Hospital on December 27. A 
second case {Case 49) in this family appeared on December 31, four 
days after return of T. 

H. was discharged from the Fever Hospital on iNTovember 10. A 
second and a third case ( Cases 50, 51) appeared in the family on Novem- 
ber 14, in both cases four days after H.'s return. 

Cases 52 to 66. 

Communicated by Dr. Abthttb WniTBLEaas, Medical Officer of Health to the 

West Riding County Council. 

Two boys, aged 4 and 8, were in the same house with a sister, who 
was taken ill one day and had rash next day. Upon the appearance of 
the rash the boys were rigidly isolated in another house. The elder 
had a scarlet fever rash three days after isolation, the younger four 
days after isolation. The intervals here were three days (about) and 
four days (about) respectively from rash to rash. 

A girl, aged 3 ( Case 54), played with a child suffering from scarlet 
fever one day, and had scarlet fever rash two days later. 

A boy, aged 2 {Case 55), was in close contact with an infected child 
for a short time only, and had scarlet fever rash five days later. 

A young man aged 22 {Case 56) was in the same house with his 
sister, who was taken ill one day, and had the rash the next day. Upon 
the appearance of the rash the young man immediately left home, but 
had scarlet fever rash five days later. 

A servant girl aged 20 (Case 57) visited her home, where her brother 
was recovering from scarlet fever, on Sunday evening, between 6 and 
9 P.M. She afterwards returned to the house in which she was in 
service, and did not go out again. On Tuesday morning she had 
scarlet fever rash, about thirty-six hours after visiting the infected 
home. 

B., a girl aged 19 {Case 58), slept one night with a cousin who was 
undergoing a second desquamation on the feet, eight weeks after the 
original attack. B. had scarlet fever rash four days subsequently. 

A boy aged 2 {Case 59) came to Nottingham from an infected 
household in the country, and had a scarlet-fever rash four days later. 

A woman aged 22 {Case 60) left an infected house in Ireland, and 
had a scarlet-fever rash in Nottingham five days later. 

A girl aged 2 (Case 61) was sent away from an infected house, and 
had scarlet fever rash four days later. 

A girl aged 12 {Case 62) left an infected house and had a scarlet 
fever rash ten days later. 

A girl aged 12 {Case 63) was admitted to a scarlet fever ward upon 



158 Scarlet Fever. 

A mistaken diagnosis one day at noon. Two days later she had high 
temperature and vomiting, and in the evening a scarlet fever rash 
appeared — about fifty-four hours after admission to hospitaL 

A ^rl {Case 64), desquamating after scarlet fever, went to live in a 
household, and a boy aged 5 years had scarlet fever rash five days later. 

A girl, X., coming from a house in which scarlet fever was prevalent, 
and herself suffering from a sore throat, the specific nature of which 
was not recognised, went to reside in another house. Seven days after 
X's arrival, a ^1, aged 2 {Ccue 65), in the house had scarlet-fever rash. 
A succession of cases followed in this household, the last being that of 
a girl aged 3 {Case 66) who returned to the house after seven weeks' 
absence, and had scarlet-fever rash six days later. 

Cases 67 to 69. 

€ommimicated by Dr. Hugh W. Stathak, Medical Officer to the Foundling 

Hospital. 

A boy in the infants' school of the Foundling Hospital had scarlet 
fever rash on August 3. On August 8 three other ii^Guit school boys 
were admitted to infirmary for scarlet fever rash. 

Case 70. 

Commamcated by Sir GsosGhB Buchaitak, M.D., F.Et.S. 

'* First two cases in the town of Dartmouth in 1870. Case A was 
ailing on February 7, rash observed February 9 ; means of infection 
doubtful. Case 6., brother of A., living in the same house, sickened on 
February 15 " {Case 70) six days from A.'s rash. 

Cases 71 to 73. 

Oommanicated by Dr. C. Haig-Bbown, Medical Officer to the Charterhouse 

School, Godalming. 

At the end of 1887 an outbreak of scarlet fever occurred at Charter- 
house, Godalming. The school reopened on September 19. At this 
time scarlet fever of a mild type was prevalent in the East of London^ 
and on September 24 one of the boys, L., received a parcel of new clothes 
which had been put out for sewing in the East End. L. opened the 
parcel in his cubicle at 9 p.m. on September 24. L. had scarlet fever 
on October 1 ; two other boys — O. and B. — ^intimate friends of L.'s, and 
sleeping near him, also had scarlet fever on the same day — October 1, 
seven days after the parcel was opened. An epidemic ensued, all the 
cases being of a mild type. 

Cases *74i to 93. 
Communicated by Mr. J. Scott Battams. 

A. B., a child with a bum of the arm, was admitted to the East 
London Hospital for Children, Shadwell, on the morning of iNTovember 
24, and in the evening of the same day she came out with scarlet fever 
rash, and was sent to the Fever Hospital that night. During the after- 
noon of November 24, 0. D. {Case 74) was nursed with A. B. on the 
same nurse's lap. 0. D. left the hospital on November 25, but was 
brought back with difficulty of swallowing and a scarlet-fever rash on 
the morning of November 30, six days after admission of A. B. 

E. F. {Case 75), who had been admitted for ulceration of the vulva, 



Scarlet Fever. 159 

slept in the next oot to that in which A. B. was placed on November 
24. On December 2, E. F. complained of sore throat and vomited, eight 
days after admission of A. B., and on December 3 scarlet-fever rash 
appeared. (The above cases were published in the British Medical 
Journal, vol. ii, 1882, p. 1248.) 

The following cases communicated to the Committee in 1889 were 
observed at the East London Hospital for Children, Shadwell, and were 
selected by Mr. Battams as having all been infected after admission, 
cases in which there was a probability of infection before admission 
being excluded. All the cases were known to have been exposed to in- 
fection after admission. 

Case 76. — James M., admitted September 28 for ansBmia. Tempera- 
ture normal till October 3 ; rash October 5, seven days after commence- 
ment of exposure. 

Case 77. — Arthur H. was admitted for genu valgum on November 16 
into a ward in which there had been a case of scarlet fever on No- 
vember 13; another child in this ward {Case 81) came out with rash of 
scarlet fever on November 21. Arthur H.'s temperature remained 
normal until November 21; rash on November 23, seven days after 
admission and two after commencement of the last case in that ward. 

Case 78. — ^Nurse B., in good health, and not previously exposed to 
infection, came up from the country and began dutv as a probationer 
on January 24. She was exposed to the infection oi scarlet fever, and 
on February 1 (eight days after entering the hospital) she vomited, and 
had sore throat *' very like scarlet fever ;" no rash was noticed, but 
temperature was high, urine contained a trace of albumen, and de- 
squamation was noticed on February 8. (On February 24 she 
developed diphtheria, and died February 27.) 

Case 79. — ^Nurse M., in good health, and not previously exposed to 
infection, came to hospital and commenced duty in above ward on 
February 5 ; she nursed, among others, a boy (admitted January 24) 
who was removed with scarlet fever on February 10. Nurse M. 
developed scarlet fever on February 15 (five days after the boy was 
removed). 

Cases of Injuby ob in which an Operation had been peb- 

FOBMED. 

a. Cutting Operations, 

Case 80. — Lydia M., was admitted on September 10, and a lipoma 
removed from the arm that day. The temperatui-e was normsd till 
September 16 ; rash September 17, seven days after operation. 

Case 81. — Edward G., admitted November 15. Operation for cleft 
palate November 18 ; rash on November 21, six days after admission, 
three days after operation; last case of scarlet fever in this ward, 
September 13. 

Case 82. — ^Arnold W., admitted August 24. Tonsils removed 
August 30. He remained quite well with normal temperature up to 
September 21, when operation for cleft palate was penormed. Rash 
September 24. *' Infection in hospital certain." 

Case 83.— Robert B., aged 8, was brought to the hospital in a private 
conveyance on February 28, was circumcised, and returned home 
without seeing any other patient. At home he was kept in bed in a 



160 Scarlet Fever. 

room by liimself, and was attended only by bis mother. He was 
brought to the hospital ag^in on March 3, and sat for some time on a 
form in close contact with a child who attended to have a scald dressed 
and was found to be ** full out in scarlet fever rash." Robert B. was 
taken home as before, entirely isolated and attended only by his mother. 
His mother stated that he vomited on March 10, was feverish, com- 
plained of sore throat, and the skin was red (seven days after exposure). 
On March 11 he was brought to the hospital, and found to be " fdll out 
in scarlet fever rash." There were no other children in the house, and 
there had been no scarlet fever. 

p. Other Operations and Injwries (except Bums and Scalds), 

Case 84.— Mabel G., admitted with injury to elbow on October 27. 
The temperature remained normal until October 29. Bash on Octo- 
ber 31, four days. 

Case 85. — George C, admitted on November 19 with a sinus in the 
neck. He vomited on November 23 (four days), and had rash on 
November 25 (five days). 

Case 86. — Mary S., aged 10 months, was admitted on November 22 
for stricture of anus ; faeces were scooped out. The temperature was 
normal till November 29. Bash same day (seven days after operation). 

Case 87. — Ethel C, admitted May 9 with ozoena and keratitis. 
Temperature normal till May 12 (three days). Bash May 13. 

Case 88. — Edward O. was admitted on February 28, and sounded for 
stone. He remained quite well until March 3, when the temperature 
was 103° F. (three days). Bash March 4. 

y. Scalds and Bwms. 

Case 89. — Joseph L., admitted November 25 with scald of chest. 
Bash November 27 (two days). 

Case 90. — Ellen M., admitted January 8 with bum of face. Bash 
January 11 (three days). There had been no case of scarlet fever in the 
ward for three weeks, and the admission of cases to that ward had been 
stopped for that period. 

Case 91. — Harry K. was admitted on February 12 with scald of back. 
Bash February 13 (one day). The ward had been cleaned and fumigated 
with sulphur since last case. 

Case 92. — ^Edward C, admitted on March 4. Bash March 7 (three 
days). There had been no case in the ward since February 16. 

Case 93. — Olement D., admitted January 23 for scalds. Bash 
January 25 (two days). Two children in adjoining beds removed with 
scarlet fever on January 22 and 24. 

The following table summarises the facts in the foregoing notes : 



Sedrlet Fever. 



161 



'S 

& 

81 
82 
80 

91 
89 
93 
90 
92 

84 
87 
88 
85 
86 


Nature of operation. 


Scarlatina appeared. 


First symptoms.' 


Aash. 


After 
admission. 


After 
operation. 


After 


After 
operation. 


 

Cuti 

Cleft palate 

f> • • • 
Excision of lipoma . 

Sec 

Scald .... 

M • • • • 
»» .... 

Bam «... 

Other Opi 

Injury to elbow 
OzsBna and keratitiB 
Sounded for stone . 
Sinus in neck . 
Anal stricture ; faces 
scooped out . 


Hng Oper 

6 

lids and J 
srations a 

2 
8 
3 

4 

7 


ations. 

6 

3v/m8. 
nd Injwn 

8 


6 
81 

7 

1 
2 
2 
8 
8 

S8. 

4 
4 
4 
6 

7 


3 
3 

7 

4 



Communicated by Sir George Buchanan, late Medical Officer 

to the Local Government Board. 

Coise 94. 

Dr. H. F. Pabsonb' Report to the L. G. B. on the Prevalence of Scarlet and 
Enteric Fever in the Castleford Beg. S. D., &c. (May 24, 1880). 

In January, 1879, there was a large family gathering at a funeral 
in Methley. It was attended by persons from Castleford, who brought 
a child with them ; these persons had scarlet fever in their house at the 
time. A child living at Methley, who was at the funeral, was taken ill 
with scarlet fever three days afterwards, and died after two days' illness* 
This was the first case in Methley. 

Cases 95, 96. 

Dr. Pabsoks' Beport to the L. G. B. on the Prevalence of Scarlet Fever at 

Potton, &c. (December 28, 1882). 

Two children who contracted scarlet fever at home sickened about 
August 27. They passed through slight attacks, and went back to 
school about September 17. On September 20 and 25 two children of 
different households attending this school were taken ill. 

L 



162 Scarlet Fever. 

Cases 97, 98. 

Dr. Paob's Report to the L. G. B. on the Continued Prevalence of Scarlatina 

in the Wisbech B. S. D. (April 3, 1883). 

On Jannarj 15 a mother and child residing in a farmhouse in 
Wisbech Fen went to a shop in a neighbouring vmage, and there came 
in contact with some members of the shopkeepers' family who were, 
or had very recently been, suffering from scarlet fever. The child 
(CiMe 97) siekened on January 17, the mother {Case 98) on January 19. 

At Upwell scarlet fever began earlier in the year, and gradually 
increased. The main outbreak was in July, and Dr. Page notes that 
the following entry appears on the school log-book : " July 13. — Flower 
show. July 17. — The schools were ordered to be closed owing to the 
sudden outbres^ of scarlet fever. There are nearly twenty cases between 
the schools and Church Bridge." 

Oaset 99, 100. 

Dr. Pagb's Report to the L. G. B. on Recent Prevalence of Scarlet Fever at 

Donington and Moulton, &c. (April 9, 1883). 

*' Infection ca&ried by am, individual with ulceraied sore throai. — The 
epidemic in Moulton originated thus : — H., a young man, came from a 
village at a distance, sufieringfrom ulcerated sore throat, for which he 
sought medical treatment. When recovering from his throat illness 
he " habitually visited '* the house of a relative who had four children. 
One of these foUr had mild scarlatina, which began about November 18. 
The other three children continued to attend school, and on November 
25 a boy, aged 7, attending the school began with scarlatina, and there- 
after other cases occurred. 

Infection carried by a heaUhy person, — ^The school was closed on 
December 15, and on that day the assistant mistress, who had not had 
any even slight attack, went to stay at her brother's houseman isolated 
farmhouse, the inmates of which had not been exposed to any other 
risk of infection. Within the same week of her arrival two of her 
brother's children, aged 2 and 4, were laid up with scarlet fever. 

Dr. Pabsons' Supplemental Report to the L. G. B. on the Continued Prevalence 
of Diphtheria and Scarlet Fever in the Sntton-in-Aahfield U. S. D., May 8, 
1888. 

Infection transmitted by mild umrecognised tases, — Dr. Parsons, in 
remarking on the difficulty of diagnosing between diphtheria (q. v.) 
and scarlet fever, especially in slight and transient cases, says that he 
was informed that during this epidemic there were " many mild cases 
of sore throat " which were not seen by any medical man, and that 
''in some such cases the subsequent occurrence of dropsy has indicated 
their scarlatinal nature." 

Dr. Blat all's Report to the L. 6. B. on a Widespread Epidemic of Scarlatina 

in . « . » . Lower Brixham (March 8^ 1889). 

Within three days of the reopening of the schools on September 3, 
three duldren returned home from school ill with scarlatina. It follows 
that they had attended there when incubating the disease, and thej 
yrere in all probability the means of introducing the disease into the 
schools. 



Scarlet Fever. 163 

Instances were met with repeatedly of attacks following a few days 
after a visit to see the body of a child dead of the disease, or 
a.ttendance at the funeral. The f ollowing^ezample is given : — " A child 
was taken to see the dead body of its little friend, and three or four 
days afterwards was attacked with scarlatina, and died within the 
fortnight; subsequently the three remaining children suffered from 
scarlatina, and the mother from sore throat, while the father suffered 
from erysipelas." 

Many persons stated that the first time their children went out after 
the fever was to witness the ceremony of laying a memorial stone on 
the spot where the Prince of Orange landed. Others stated that their 
children were well when they went to see the stone laid, but four or 
five days afterwards they were " down with the fever." 

Cases 101 to 112. 

Communicated by Dr. W. Tok&e- Smith in a Letter to Dr. Buchanan, and 
Paper in Brit. Med. Joum., 1883, vol. i, p. 160. 

Case 101. — " S. B., certified as scarlatina, was brought to hospital 
in a scarlet fever ambulance on the evening of May 30, 1879. He was 
found to have morbilli, and was isolated. May 31 : The rash of mor- 
billi had almost disappeared. June 1 : Temperature 99^ ; he fdt quite 
well. June 2 : 8 a.m., temperature 103*2° ; headache and sore throat. 
II a.m., scarlet rash, &c. Incubation, about sixty hours." 

Case 102. — " J. B., certified as having scarlet fever, had an hour'» 
drive in a scarlet fever ambulance between 5 and 6 p.m. on December 
27, 1879. On arriving at the London Fever Hospital he was found 
to have scarlatina, and was isolated. At 7 p.m. on December 30 the 
temperature was 99*8°, followed by sore throat, vomiting, scarlet rash, 
Ac. Incubation, about seventy-two hours." 

Case 103. — " E. R., certified as having scarlet fever, was brought in a 
scarlet fever ambulance on April 8, 1880, at 3 p.m. He was found to 
have rubeola, and was isolated. On April 10, towards night, he had 
^ght sore throat ; temperature normal. On the 11th, in the morning, 
his condition was the same. Towards evening his temperature was 99° ; 
throat much worse, followed by sickness, rash, &c. Incubation, about 
seventy-two hours." 

Case 104 — " S. G., certified as having scariet fever, was brought in 
the scarlet fever ambulance on March 29, 1881, at 3 p.m., and was found 
to have rubeola, and was isolated. No symptoms of scaiiatina appeared 
till April 1, at 7 a.m., when the patient had headache, sore throat, fever, 
.and then rash, &c. Incubation, sixty-four hours." 

Case 105. — " H. H., on the morning of October 30, 1879, met friends 
at Begent Circus, and rode with them in an omnibus to the Marble 
Arch. There he left them, and had no further communication with 
them. He had not had anything to do with them for some weeks pre- 
vioudy, as some members of the family were ill with scarlatina. Two 
of those whom he met had themselves been taken ill with scarlatina 
about three weeks before. The boy continued well till November 2, 
1879, when, in the morning, he had sore throat, followed by rash, &c. 
Incubation, about seventy-two hours." 

Case 106.—'* J. O'B., certified as having scarlatina, was brought from 
an important hospital and medical school, and was said to have been 
isolated some days. He reached the London Fever Hospital at 11 A.M. 



164 Scarlet Fever. 

on November 4, 1879. There was no sign of scarlatina or other acnte 
specific disease. On faith in the authority (I very soon got over faith 
in the authoritv) I myself pat the patient in the scarlet fever ward.. 
No symptom of anything wron^ appeared nntil November 7, when, at 
9 A.M., he had sore throat, and his temperature was rising. At 1 p.m. 
he had scarlatinal rash, &c. On the 10th desquamation was beginning. 
Incubation, seventy hours, not more." 

CcLse 107. — '' A. B., certified as having scarlet fever, was placed in the 
scarlet fever ward on the afternoon of December 24, 1879. On Decem- 
ber 26 he was feverish at night ; temperature normal. On December 
27, during morning, the temperature was lOP ; in the afternoon he had 
sore throat, rash, &c. Incubation, about sizty-four hours, not more." 

Case 108. — " M. P., nurse at the London Fever Hospital, arrived on 
April 1, 1880, at night. On April 2, at 7 a.m., she for the first time 
entered the scarlet fever wards, and remained on duty in these wards 
until April 5, when, shortly after 7 A.M., she suddenly had sore throat,. 
&c., followed by rash. Temperature 103^. Incubation, about seventy- 
two hours, not more." 

Cflwe 109. — " M . P. 0., ward-servant, began work on entering hospital 
at 9 A.M., March 28, 1^1, and remained well till 3 p.m. on Apnl 1,. 
when she had sudden sore throat ; temperature 103*6°, followed by rash, 
&c. Incubation, one hundred and two hours, not more." 

Ccuie 110. — '* G. H. was sent in with Case 106, at the same time, from 
the same place, under the same conditions, and by the same authority. 
There was no sign of illness. In a credulous mood I myself put the 
patient in the scarlet fever ward. There was no sign of scarlatina 
whatever till November 17, 1879, in the afternoon, when he had sudden 
vomiting, sore throat, &c., followed by scarlet rash , temperature 103'4°. 
He desquamated subsequently. Incubation, thirteen or fourteen days (P), 
not more, certainly. These were the only two cases sent in; both 
recovered perfectly." 

This case. Dr. Tonge-Smith remarks, " shows nothing more than 
that it is possible to live in the midst of the infection of scarlatina for 
a fortnight without showing signs of the disease. Amongst nurses and 
servants I have known of several such cases, which have little practical 
importance. In this connection I may remark that 1 have known some 
cases lie in bed in a well- ventilated scarlatina ward for two or three weeks 
and not develop the disease, but to do so towards the end of the third 
day after getting up and coming to closer quarters with the other 
patients." 

Case 111. — "A young lady visited a dressmaker on February 11, 
1880. She saw there a sick child (the mother said it had sore throat). 
She went again on February 12 to have her clothes fitted, and again 
saw the child. On February 15 she was attacked with scarlatina. 
Incubation, about seventy-two to ninety-six houra" 

Case 112. — " A sister of Ca^e 111 left home before her sister was 
attacked, and in consequence stayed with a friend. She visited the 
same dressmaker on March 10, 1880, at 5 p.m. On March 12 she went 
again to be fitted. On the 15th she had sore throat, &c., followed by 
scarlatinal rash. Incubation, about seventy-two to one hundred and 
twenty hours." 

Dr. Tonge-Smith adds, " Since ^ettins the above facts of these two 
cases I have been told that possiblj there may have been another 
source of infection common to both sisters, that of a young lady who 



Scarlet Feven 165 

bad an illness which her friends thought might have been scarlatina, 
but which the medical attendant said positively was not." 

If the disease in Cases 111 and 112, he adds, ''were contracted 
from the child, though they differ in their maximum limit, they 
strangely agree in their minimum — seventy- two hours ; and this, more- 
over, dates m each case from the most important point in the history — 
that is, the trying on of the clothes, whicn had lain for twenty-four to 
forty hours in the supposed infected house." 

Cases 113 to 118. 
Commnnicated by Dr. W. Sqttibe. 

These cases were published by him in his JSssays in Preventive Medicine, 1887, 

p. 87. 

A boy (Case 118) went to meet his sister, who had commenced with 
scarlet fever sixty-six days before, at the station, and sat opposite to 
her in a closed carriage. She had been in quarantine for a month, 
and her return took place on March 20. On March 22 the boy was 
ill, vomited, and was restless at night; on March 23 he had sore 
throat and rash — less than two days from return of sister to initial 
symptoms in boy. 

A girl (Case 114), aged 10, came from school with scarlet fever on 
July 4. On August 14, six weeks after commencement of her illness, 
she joined her two younger brothers at the sea-side. The youngest, 
aged 5, had sore throat on August 16, and the full rash of scarlet fever 
on August 20 — two days from return of sister to sore throat. 

Two children, A. and B., lived in an isolated house. On February 
17, A. (Case 115), aged 4, was taken to a London hospital ; infection was 
attributed to a child met on this occasion, the only one on which any 
communication with others could be traced. On February 19 A. 
vomited ; on February 20 she had sore throat, and the rash appeared on 
February 21. B., aged 2 (Case 116), had some difficulty in swallowing 
on the evening of February 20 (before the rash had appeared on A.), 
was ailing on February 21, and had rash on February 22. 

A boy who had been at a school broken up on account of an epidemic 
of scarlet fever, and who had himself had a sore throat, returned home 
on December 3, 1861. On December 6 the mother (Case 117) became 
ill (three days after boy's return) and on December 7 she had rash of 
scarlet fever. One of the boy's sisters, aged 11 (Case 118), who was 
isent away from home on December 7, had scarlet fever on December 12, 
five days after leaving home. Two other sisters, aged 12 and 10 respec- 
tively, who went away with the girl aged 11, escaped altogether. 

Cases i to Ixxv. 

Cases communicated to the Society in 1878 by the late Dr. MuBCHlsoiir 

(Trctnstictions, vol. xi, p. 250). 

Case i. — A female, aged 22, was admitted into the London Fever 
Hospital on April 22, 1858, on the third day of an attack of scarlet 
fever, which proved fatal on the eighth day. On April 19 she had 
come from a part of Oxfordshire where scarlet fever did not exist, to 
«ee her sister, who was lying dangerously ill with it in London. She 
arrived in the afternoon, and on the following morning she was seized 



166 Scarlet Fever. 

wiih rigors, headache, and sore throat, and on the 21st a scarlet rash 
was obserred on the skin. Here the period of incubation did not exceed 
eighteen honrs. 

Case iL — ^Ann W., aged 18, a servant, was admitted into the London. 
Fever Hospital, suffering from scarlet fever, on October 5, 1863. On 
September 28 a young lady had come from school to the house where 
Ann W. was in service, ill with scarlet fever, and was waited on by her 
on the same day. The next day Ann W. was seized with sore throat,, 
followed by the usual symptoms of scarlet fever. In this case the 
period of incubation did not exceed twenty-four hours. 

CoLse iii. — For the details of this case 1 am indebted to the late Mr^ 
Marson, of the Small Pox Hospital. About twenty years ago, a family 
residing in Gray's Inn Lane gave a children's party. Before the day 
one of their own children fell ill with scarlet fever. Not wishing to 
put off the party* the child was removed to a garret. The party took 
place on a Monday, the children being at the house from about 4 to 9 
P.M. On the Tuesday, between II and 12 p.m., a child, residing in a 
distant part of London, who had attended the party, but was not known 
to have been otherwise exposed to scarlet fever, was seized with the 
usual symptoms of scarlet fever, of which she died on the Friday 
morning. In this case the period of incubation was somewhere 
between twenty-six and thirtv hours. 

Case iv. — Chi March 19, 1869, about 3 P.M., Mrs. T., aged 4fO, had a 
small tumour removed from behind her left ear, by the late Sir William 
Fergusson. On the evening of the 20th she was taken very ill with 
fever and vomiting. On the 2l8t her face and chest were covered with 
a punctated scarlet rash, which, on the 22nd, when I saw her, had 
extended to the legs, and had all the characters of scarlatinal rash.. 
The other symptoms of scarlatina were also present. On inquiry it 
was ascertained that the nurse who had come to attend on Mrs. T., 
shortly before the operation on the 19th, had just left off nursing a 
child ill with scarlet fever. Here the period of incubation was less than 
thir^ hours. 

Case V. — Mary B., aged 21, was admitted into the London Fever 
Hospital on September 14, 1863, on the fourth day of an attack of 
scai'Iet fever. She had been in service, and on the evening of Septem- 
ber 9 she had gone to a " new place," at a house at which some of the 
inmates were suffering from scarlet fever. On the morning of the 11th 
she had been seized with vomiting and sore throat, followed bv all the 
ordinary symptoms of scarlet fever. In this case the period of incuba- 
tion was less than thirty-six hours. 

Case vi.— On March 4, 1863, about 4 p.m., W. F., aged 11, a school- 
boy, went with some of his schoolfellows to a house in which there 
were cases of scarlet fever, and remained there about two hours. Early 
in the morning of March 6 he was seized with scarlet fever, which was 
followed by gastro-enteritis, terminating fatally on March 23. Here- 
also the period of incubation did not exceed thirty-six hours ; but it 
could not have been much shorter. 

Case vii. — On the eveni ng of February 23, 1878, Mrs. M. went from 
Hampstead to a school at Wimbledon, to nurse her son who was ill 
with malignant scarlet fever, and on the morning of February 25 she 
awoke with sore throat and other symptoms of scarlet fever, which ran 
a mild course. Here also the period of incubation did not exceed 
thirty-six hours. 



8ea/rlet Fever^ 167 

Cases viii to z. (See below, " Milk Oases," pa^o^ 171.) 

Case xi. — The following case was commim^ated to me by Dr. 
Alfred Wiltshire, after reading my paper in the La/ncet of Augast 
13^ 1864, on the latent period of scarlatina : 

On March 1, 1864, Mrs. M. took her two children, Bobert, aged fonr 
and a half, and his brother, aged two and a half, to Uniyersity Oollege 
Hospital, the latter having rickety deformi^ of the legs. They were 
in the out-patient room from 2 to 4 p.m. While there Mrs. M. sat next 
to a woman nursing a child who was verv ill and had its throat 
wrapped up, and the woman told Mrs. M. that she had four other 
children at home ill with ** scarlatina and diphtheria." Mrs. M. kept 
her younger child in her arms, but Bobert stood at her side next to the 
woman with the sick child. Early in the morning of March 3 Bobert 
was taken ill with shivering, sickness, and drowsiness ; in the evening 
of the same day a scarlet eruption began to appear on the skin, which 
next morning was very copious and bright all over the body ; and on 
March 8 the boy died. The younger child sickened with scarlatina on 
March 10, and died with pysBmic abscesses on April 7. In Bobert's 
case the period of incubation was not longer than forty hours, and not 
shorter than thirty-six hotirs. 

Case xii. — Mrs. H., about 30 years of age, student of medicine, care- 
fully examined the rash of a child su£fering from scarlet fever at 2 p.m. 
on March 8, 1878. The examination did not last longer than ten 
minutes, and she only saw the child on that one occasion. On the morn- 
ing of March 10 she awoke with sore throat and fever, and next morning 
she had a copious and typical scarlatina rash. Here the period of in- 
cubation did not exceed forty-one hours, and was probably not shorter 
than thisty.six hours. 

Case xiii. — On June 10, 1876, a child, A., left Lincolnshire, and 
arrived in the evening on a visit to a family residing at Shooter's Hill, 
near Greenwich. She was then apparently in good health, and there 
was no illness in the house in lancolnshire from which she came. 
But in the night of June 11-12, two children, B. and 0., sickened with 
scarlatina in this house in Lincolnshire ; and in the same night A., and 
D., aged 6, who occupied the same room as A., and had not been away 
from Shooter's Hill, nor otherwise exposed to scarlatina, fell ill wii^ 
this disease. 

If A. fell ill first, and D. contracted the disease from her, there 
could have been scarcely any period of incubation ; but if, as seemed 
more probable, the poison was in the clothes of A., or A. gave off the 
poison during the incubating stage, the period of incubation in D. may 
have been forty-eight hours, but not longer. 

Case xiv. — Mary Jane G., aged 5, was admitted with scarlet fever 
into, the London Fever Hospital in the afternoon of June 20, 1865. 
Her brother had been brought home convalescent from scarlet fever on 
the 18th, and in less than forty-eight hours afterwards Mary Jane was 
taken ill, and brought at once to the hospital. The period of incuba- 
tion was less than K>rty-eight hours. 

Case XV.— On April 12, 1868, Caroline A., aeed 21, was engaged as a 
nurse in the London Pever Hospital, and on the same day she began 
duty in one of the scarlet fever wards. On April 14 she was taken ill 
with what turned out to be a severe attack of scarlet fever. The period 
of incubation did not exceed forty-eight hours. 

Case xvL — ^Alexander D., aged 6, arrived from a locality in Scotland 



168 Scarlet Fever. 

where scarlet ferer was then unknowii, at an hotel near Fiocadilly, late 
in the eyening of March 22, 1873. There had heen cases of scarlatina 
shortly before in this hoteL The exact particulars were kept back ; bat 
it was ascertained that a servant, ill with scarlet fever, had been 
remoTed from the hotel to a fever hospital a fortnight before, and that 
some other of the inmates had had sore throat. On the evening o£ 
March 24, A. D. was taken ill with sore throat, and next morning, when 
I saw him, he had a scarlatina rash. In this case the period of incuba- 
tion did not exceed fortj-eight hours. 

Case xviL — Charles D., aged 4, came with his brother, A. D., from 
Scotland to Piccadilly on March 22, 1873. (See last Case.) G. D. 
awoke at 3 a^m. on March 27 with vomiting and pyrexia, which were 
the first symptoms of a Ijpical attack of scarlatina. Here the period 
of incubation could not in any case have exceeded four days and six 
hours ; but, on the supposition that 0. D. caught the disease from his 
brother, which was probable, as they occupied the same room, it did 
not exceed fifty-four hours. 

Case xviiL — Mary H., aged 24, a nurse at the Henrietta Street 
Nursing Institution, went to nurse a child badly ill with scarlet fever 
on the evening of March 12, 1865. During the 13th and 14th she did 
not feel very welL On the morning of the 15th she had sore throat 
and vomited, and in the afternoon the rash of scarlatina appeared. On 
March 16 she was admitted into the London Fever Hospital, suffering 
from scarlatina. The period of incubation in this case could not have 
exceeded two and a half days. 

Case xix. — Miss B., aged 12, returned to school at Kensington on 
October 5, 1858. A girl at the school was ill at the time with scarlet 
fever. On October 8 Miss B. felt feverish and had a sore throat, and 
on October 9 the rash of scarlet fever made its appearance. The 
disease ran its usual course and terminated favourably. The period of 
incubation in this case could not have exceeded three days. 

Case XX.--T. M., an o£Gicer in the Limerick Artillery, aged 22, 
arrived in London on September 2, 1858. On September 5, in the 
afternoon, he visited a friend, whose little girl had scarlet fever, but so 
slightly that she was not confined to bed. He took the girl on his 
knee and kissed her. On the morning of September 8 he was quite 
well, but towards evening he was attacked with headache, heaviness, 
and sore throat, followed by a dusky scarlet rash, ulcers on the tonsils, 
constant delirium, sleeplessness, and gi*eat prostration. He died on 
September 14 at 11 a.m. In this case the period of incubation was not 
longer than three days, but neither was it shorter. 

Case xxi. — Susan W., aged 16, was admitted into the London Fever 
Hospital on January 13, 1863, along with her sister, who was ill with 
typhus. Susan's febrile attack terminated on the seventh day (January 
15) with an eruption of herpes on the lips. She never had an^ typhus 
eruption, and on January 16 her pulse was 60 and her appetite good. 
In the night of January 16 she beean to complain of pains in the 
Umbs and sore throat, and next day die rash of scarlet fever appeared, 
and the pulse was 108°. Although this patient was admitted with her 
sister into a typhus ward, she was attended by a nurse from a ward 
devoted to scarlet fever. The period of incubation in this case could 
not have exceeded three and a half days. 

Case xxii — ^Ellen N., aged 4, was admitted into the London Fever 
Hospital on May 2, 1863, on the fourth day of an attack of scarlet 



Scarlet Fever. 169 

fever, wliicli proved fatal from pneumonia on the eleventh day. This 
•child had been living in a locality where scarlet fever was not known 
to exist, bat on April 25 she had been taken to the workhouse of St. 
Greorge's-in-the-East, and on the same day she had played there with a 
•child who was then sickening with scarlet fever, and who was admitted 
into the London Fever Hospital with this disease in a malignant form 
on April 27. Ellen N. was taken ill with headache and sore throat on 
April 29, and the scarlet rash appeared on April 30. Here the period 
of incubation could not have exceeded four days. 

Case xxiii. — In the afternoon of May 14, 1863, while from home, I was 
myself seized with general pains, fever, sore throat, and great prostra- 
tion. I did not get home until eleven o'clock, and all next day I was 
very ill in bed with the same symptoms, but there was no rash. Sus- 
pecting that I had scarlatina, 1 sent for a medicsd friend to advise me 
3S to sending away my only child, but, by the time that he arrived, 
late in the evening, I was so much better that he gave a decided 
opinion that my attack was not scarlatina, and next morning, as 1 was 
able to get up and attend to my duties, I believed that he was right, 
and did not send my child away. I have no doubt now from the sequel, 
•and from what I have seen in other cases, that my attack was scarlatina. 
I may add that at the time I was much exposed to the disease, that I 
never had scarlatina before, nor have I had it since, and that for many 
months after that attack I was very anaemic and out of health. On and 
after May 16 I saw my child as usual. On the morning of May 20 she 
was attacked with scarlatina in a malignant form, of which she died on 
the 27th. The period of incubation in this case could not have exceeded 
four days. 

Case xxiv. — On April 1, 1878, Master P. left school at Wimbledon 
on the fortieth day of an attack of scarlatina for his home at Brighton. 
Before leaving, desquamation had to all appearances quite terminated, 
the feet having desquamated twice. Also he had had repeated carbolic 
acid baths, and he had left all his infected clothes behind. After 
reaching Brighton his face and feet desquamated again, and four days 
^ter his arrival his mother fell ill with scarlet fever. Here also the 
period of iniAibation did not exceed four days. 

Cases XXV to liv. — The following remarkable history was communi- 
oated to me in 1865 by Dr. J. Hogarth Pringle, then at Parramatta, 
New South Wales, in reference to my papers on the Etiology of Scar- 
latina, which had appeared in the Lancet of the previous year. I 
•quote from his letter : 

" In the month of April, 1858, I was surgeon of one of the large 
steamships, plying between Australia and Suez, in the Boyal Mail 
Service. We \^ Sydney in April, carrying 147 first-class pas- 
sengers, of whom upwards of forty were cmldren under ten years of 
age. We had no sickness on board until one day after leaving Aden, 
or forty-six days after leaving Sydney, when scarlatina made its appear- 
iince, and before reaching Suez (four days) thirty cases had occurred. 
Now, when we left Sydney there was no scarlet fever there, nor was 
there any at Melbourne, Kine George's Sound, Galle, or Aden, the 
only ports at which we touched. I was most careful to ascertain this 
on my return passage. But a family on board had up to nearly three 
weeks before their embarkation resided with friends in Queensland who 
had scarlatina. None of the family who were on board had at that 
time contracted the fever; but the light clothing they had worn in the 



170 Scarlet Fever. 

semi-tropical heat of Queensland had been packed up there for the 
TOjage, and the boxes had not been opened nntil after leaving Aden, 
and reaching the terrible snmmer-heat of the Bed Sea, when it was. 
unpacked and again called into use. It was in this family that the 
two first cases occurred, after an intenral of upwards of three months 
since they and their infected garments had left the house in Queens- 
land where scarlet fever had ri^ed. The rapidity with which the 
disease was developed in the vessel tends to prove what I think I have 
been frequently assured of, that the incubatory stage of scarlatina is 
very short." 

This is certainly a most remarkable and telling story bearing on the 
period of incubation of scarlatina. Presuming that most, if not all, 
of those attacked on board ship were children, out of rather more than 
forty exposed, thirty were attacked within four days. At all events, in 
none of the thirty cases could the period of incubation have exceeded 
four days ; in many it was probably much shorter than this, as they 
may have contracted the disease from those who first sickened rather 
than from the originally infected clothes ; while in two at least of those 
first attacked, the incubation-stage seems to have been less than twenty- 
four hours. 

CcLse Iv. — Robert W., aged 44, was admitted into the London Fever 
Hospital on September 17, 1858, on the fifth day of scarlet fever. On 
September 8 he went to act for a coachman, who, with his children, 
were laid up with the disease. He did not sleep in the house, and 
never entered the sick-room, but late in the afternoon of September B 
the coachman, though ill, came out to speak to him, and gave him a 
cup of tea out of his hand. On the moi*ning of the 13th Robert W. 
fell ill with scarlet fever, the rash appearing on the 14th. The period 
of incubation in this case was four and a half days. 

Case Ivi. — Thomas B., aged 16, was admitted into the London 
Fever Hospital on October 15, 1858, on the fifth day of scarlet fever, 
and on the eleventh day he died. Four and a half days before his 
seizure he anived from sea, and went to his mother's house, where 
scarlet fever was. Three of the family had died of it, and a fourth was 
not expected to live. Here the period of incubation could not have 
exceeded four and a half days. 

Cases Ivii to Ixxii. — Part of the milk epidemic. See Caaes 117, 118. 

Cases Ixxiii and Ixxiv. — On January 10, 1864, a girl returned to the 
Sailors' Home at Hampstead from visiting a house where scarlet fever 
was. She did not take the fever itself, but on the 15th another girl in 
the home was attacked, and on the 16th a second case occurred. The 
only discoverable source of the poison was that now stated. In these 
two cases the period of incubation may have been (though not neces- 
sarily) as long as five and six days respectively, but it could not have 
been longer. 

Case Ixxv. — On a Tuesday in March, 1878, a young lady, A., sickened 
with scarlatina at a school at Putney. On the following Thursday a 
second young lady, B., left the school for her own home, where there 
was no scarlatina. On the Monday following B. fell ill with scarlatina.. 
The period of incubation was somewhere between four (not less) and six 
(not more) days. 



Scarlet Fever. 171 



MILK CASE 8. 

Cases 113 to 116. 

Communicated by Dr. Shea, Beading. 

Ab., a cowman, had scarlet fever at some time dnrmg a period of 
three weeks before February 25. On that date he entered the service 
of G. 0. On February 25 he began to milk 0. G/s cows, and 0. G. and 
his family drank the milk on l£at and the following day. On Feb- 
ruary 27 G. G. felt very unwell, and on February 28 (less than 3 x 24 
hours) G. G. and three of his children " were down with scarlet fever." 

Cases 117, 118. 

Communicated by Sir GBOsas Buchanan, M.D., F.B.S., late Medical Officer ta 

the Local Government Board. 

On June 9 various people partook of certain cream, which appeara 
from circumstantial evidence to have been the cause of scarlet fever to 
twelve people who afterwards had the disease. Six others had sore 
throat, apparently related to the same cream, at the same time. All 
fell ill between June 11 and June 14. Laura {Case 117), lady's-maid, 
was taken ill with sore throat on June 11, two days after tho dinner 
party. She had a slight rash on June 14, five days after the dinner 
party. One guest {Case 118), who partook of the cream on June 10,. 
fell ill with scarlet fever on June 14. 

The following are Dr. Murchison's notes of three of the casea 
belonging to this series : 

Case viii. — On June 13, 1875, 1 was consulted in the case of Lady A.,, 
aged 70, who had a typical scarlatina rash, with sore throat and 
redness of the fauces ; pulse 96 ; temp. 101*5^ Fahr. She had never 
had scarlet fever before ; but her daughter had had it when over fifty 
years of age. On June 9 Lady A. had. dined out at 8 p.m., returning 
home about 11 p.m. Of the sixteen persons who sat down to dinner^ 
eight were attacked within five days with scarlet fever, which there 
were good reasons for attributing to infected cream. (See Dr. 
Buchanan's report : * Reports of Medical Officers of Privy Council,* 
New Ser., No. vii, 1876, p. 72.) In the forenoon of June 11, Lady A. 
began to have fever and sore throat. In this case the period of 
incubation seemed to be somewhere between thirty-four and forty hours* 

Cases ix and x. — The Hon. Mr. and Mrs. B., aged respectively about 
50 and 40, both dined with the same party as Lady A., on June 9, 1875. 
Both were taken ill with scarlet fever early on June 11, and on June 19 
I saw them both in consultation, with great enlargement of the cervical 
glands and secondary fever. The latent period in both cases was 
probably somewhat between thirty-four and forty hours. 

Cases 119 to 126. 

Dr. AntT's Beport to tbe L. G. B. on an Outbreak of Scarlet Fever at 

Fallowfield, dated December 13, 1879. 

A remarkable outbreak of scarlet fever occurred at Fallowfield, 
three miles from Manchester, in July — August, 1879 ; 35 persons in 18 



172 Scarlet Fever. 

families were attacked witliin a period of one month ; of these 24 were 
attacked between the morning of August 3 and the evening of August 4, 
^ period of twenty-four hours. The mfection was contained in the milk 
distributed from a dairy (D). Dr. Airy considered that his investiga- 
tion rendered it highly probable (1) that the milk was infected through 
the agency of one of the milkers, a man who lived in a small ill-ven- 
tilated house in which his grandson passed through an attack of scarlet 
fever (this boy was taken ill at the beginning of July) ; (2) that a 
■specially intense contamination of the milk took place on the morning 
milking on August 2, but that on one or two previous days it was con- 
taminated in a less degree ; (3) that the period of incubation in the 
majority of cases was forty-eight hours. The following instances are 
:given : 

Case 119 (No. 11 in Dr. Airy's Report). — E. B., a female child, 
returned from an out-of-the-way residence in the country, where scarlet 
fever was untraceable, to her home two miles from Fallowfield on 
August 1. On August 2 she went to D. and had a draught of milk. 
There were smart premonitory symptoms on the evening of August 3, 
rash and fever on August 4. Dr. Thorbum, who attended her, wrote, 
" The period of incubation can have been little over thirty-six hours." 

Cases 120, 121 (Nos. 21 and 22 in Dr. Airy's Report.)—" Two boys, 
aged 14 and 16, returned from school at Wolverhamptom, where there 
had been no recent scarlet fever, on Friday, August 1. On Saturday 
and Sunday, August 2 and 3, they were at Fallowfield, and drank milk 
from the dairy D. On Monday, August 4, they left for Scotland, and 
both suffered from diarrhoea that night. On Tuesday, August 5, the 
eldest boy had a rash. The fever was not fully developed in these 
-cases, but they were very like some others in the same outbreak, and 
probably depended on the same cause." 

Cases 122 and 123 (Nos. 14 and 15 in Dr. Airy's Report), aged re- 
spectively 22 and 15 years, could not have partaken of the infected milk 
after August 2, as th^ left home at 2 p.m. on that day, had sore throat 
in the night, August 3—4, and developed symptoms of scarlet fever on 
August 4 at PwUycrochan in North Wales. 

Case 124 (No. 26 in Dr. Airy's Report), aged 6, also left home 
at 2 P.M. on August 2, and developed scarlet fever on August 4 in 
Scotland. 

Cases 125 and 126 (Nos. 17 and 18 in Dr. Airy's Report), aged 
respectively 10 and 11 years, left home on the moiiiing oi August 4, 
and were taken ill on the evening of that day at Coventry. 

The following table shows the ages, date, and nature of attack in 
the remaining cases in which infection is believed to have been due to 
the milk : — 



Scarlet Fever. 



nz 



No. of case 








in Dr. Airy*! 


Age. 


Date of attack. 


Nature of attack and notes. 


fleport. 








5 
6 


5i 
8i 


Ang. 3rd' 
« Srd/ 


Scarlet fever. 


7 


7 


„ 3rd- 




8 
9 


8 
12 


„ 3rdl 
„ 3rdf 


Diarrhoea and vomiting; severe scarlet fever. 


10 


13 


„ SrdJ 




12 


12 


,, 4th 


Attacked with scarlet fever in the morning ; had 
complained of sore throat the previous evening. 


19 


15 


„ 4th 


Scarlet fever; sore throat the previous evening. 


13 


25 


., 4th 


Attacked in the morning with sore throat; 
scarlet fever. 


16 


3 


„ 4th 


Diarrhcea and vomiting; severe scarlet fever. 


20 


11 


„ 4th 


Scarlet fever. 


23 


7 


„ 4th 


Sore throat; feverish. 


24 


3 


„ 4th") 




25 


4 


„ 4th 


\ 


27 
28 


(?)12 
6 


„ 4th ^ 
„ 4th 


Scarlet fever. 


29 


5 


„ 6th 




30 


Adult 


„ 5th^ 




31 
32 


8J 
5 


« 6th "1 
„ 7th/ 


Sore throat. 



^ The symptomB which accompanied the onset of the disease, Dr. 
Airy states, were in many cases so remarkable as to lead the medical 
men who attended them to believe that there must be something excep- 
tional in the cause or mode of infection. Not only was there frequent 
vomiting, but also severe and continued diarrhoea ; indeed, in some of 
the persons attacked diarrhoea was the most prominent and almost the 
only symptom, and in one of the earliest cases (not included in the 
above table), which occurred in an adult and did not show fuU febrile 
development, it was remarked that the symptoms were more those of 
irritant poisoning than of scarlet fever. There was, however, no doubt 
at all as to the real nature of the disease in other cases, which, with 
similar symptoms of irritation of the alimentary canal, presented also 
all the characteristics of scarlet fever. 



CaaeB 127 to 134. 

Memorandum addressed to the L. G. B. by Mr. W. H. Poweb on Epidemic 
Scarlatina and Sore Throat in Wimbledon and Merton (June 14, 1887). 

To the Memorandum is appended a report by Mr. Cooper, Inspector 
of Nuisances, Wimbledon. 

During the week following Christmas Day there was a sudden out- 
burst of scarlatina and throat illness amongst the consumers of 
Mr. B.'s milk, and such persons continued to be attacked in increasing 
numbers till January 1, when the epidemic may be said to have ceased, 
80 far as Mr. B.'s customers were concerned, his supply of milk to this 



174 



Scarlet Fever. 



-difltrict hannff been stopped on December 31, alter the completioii of 
the moming oeliTery. 

From fi»t to las t in this epidemic, i. e, from. December 23 to January 
15 following, there appear to have been 545 cases of scarlatina and 
throat illness ; of these 493 occurred amonsst the oonsomers of Mr. B-'s 
milk, being 90*5 per cent, of the total number of cases that came under 
notice. The tot^d number of persons taking Mr. B.'s milk was 1437, so 
that oyer one third were attacked. Households suffered more severely 
the larger the amount of milk taken. 

There were amongst Mr. B/s customers 11 cases on December 26, 
38 cases on December 27, 46 cases on December 28, 67 cases on Decem- 
ber 29, and 102 on December 30, after which tbe number of cases 
declineid, and in one day, from the 1st to 2nd January, fell from 76 to 
16. In another eight days, notwithstanding some cases in houses pre- 
viously invaded, and a few households not supplied by Mr. B., the 
epidemic was at an end. 

The following table contains particulars of eight cases in which 
persons attacked had only exceptionally partaken of Mr. B.'s milk a 
short time before falling ilL Li these cases the incubation period 
varied from a little more than one to five days. 



No. of 



I 
127 1 Mr. N. 
128 ' Mr. S. 
129 ' Child T. 

130 Child P. 

131 Child W. 

182 Child M. 



Benuurki aa to taking Mr. B.'a 
milk. 



133 
134 



MissD. 
Mr.H. 



Etetnmed at tea time 

Betomed in the morning 

Spent day in Merton 

Betnmed 

Spent day in Merton, and 

Shrank quantity of milk 
Drank milk at 2 p.m. on 

retoming after Christmas 
Drank glass of milk 
Ditto 



Date of 

taking tke 

milk. 



Dec. 

99 
M 

t» 

f» 
99 



28th 
28th 
30th 
30th 
30th 

28th 

28th 

3l8t 



Date of tint being 
attacked. 



** 



** 



ft 



Evening, Dec. 30th 
31st 
31st 

Night, Jan. 2nd 

Jan. 1st 

Night, Dec 29th 

Jan. 2nd 
„ 4th 



Probable 

time of 

incnbation. 


2 days. 

3 9. 

30 hoars. 

3 days. 
2 « 


30 hoars. 


5 days. 
4 „ 





On January 5 a batcher who was also a dairy-farmer bought two 
cows of the dairy-farmer who suppHed Mr. B. The butcher said he 
did not milk the cows, but scarlet fever broke out among the consumers 
of the milk from the dairy supplied by the butcher, viz : 



Jan. 7th 
8th 
9th 
11th 



99 



8 eases of scarlet fever' 
10 
9 
2 



99 
W 
9* 



#» 



9> 



and 4 cases of 
'"throat iUness.'* 



»» 



18 



Altogether there were 24 cases among the drinkers of the butcher's 
milk. 

The epidemic was very mild ; many of the cases did not present 
•distinctive symptoms, but occurred in houses where scarlet fever was 



Scarlet Fever, 



175 



present. Only 26 cases of scarlet fever or sore tliroat were heard of 
^jnong persons who were not consumers of Mr. B/s or the batcher's 
milk. There was remarkably little evidence of extension by personal 
intercourse, and in the sudden cessation of the epidemic evidence to the 
-contrary. 

Beport on certain observed Belations between Scarlatina in varioos Districts of 
London, and Milk supplied from a Dairy Farm at Hendon (Ann, Rep, of 
Med. Off. of L. a. B. for 1885, p. 82). 

Mr. Power states that on December 16 (the sale of milk from the 
suspected sheds having been stopped the previous day) some of the 
milk was given away by the cowmen to people living near the farm ; of 
the families who thus obtained the milk six were invaded, the first case 
dating from December 20. 



Scarlet Fever and the Puerperal State. 

Dr. Robert Boxall has directed attention to certain cases published 
by him in the Transactions of the Obstetrical Society of London, vol. 
XXX, which contain data as to the duration of the period of incubation 
in women during the jpuerperal period. 

Three women admitted in succession into a lying-in hospital, and 
placed after delivery in the same lying-in ward, were attacked, in the 
same order, with scarlet fever. The circumstances render it highly 
probable that they were not exposed to infection until after labour was 
complete, when they were transferred from the labour to the lying-in 
ward ; in this ward they were attended by the same night-nurse as was 
in charge of another ward in which a woman was attacked with scarlet 
fever on April 23, 1884 ; this woman was removed to a fever hospital on 
April 25. The dates in the three cases which followed are given in the 
following table compiled from Dr. Boxall's tables : 



No. of case. 




Delivery. 


Attacked. 


In this 
list. 


In 

author's 

list. 


Date of 
admission. 


Date. 


Honis Hours 

after after 

119. 120. 

1 


Honis 
after ad> 
mission 

to 
hospital. 


Hours 

after 

delivery. 


Hours 
after ad- 
mission 
to lyine- 
in ward. 


After 
119. 

18 
30 


After 
190. 

12 


135 
136 

! 137 

i 


X 

• 

XI 

• • 

xu 


April 25. April 26, 
9.55 a.mJ 1 p.m. 

April 26, AprU 26, 
4 a.m. 7.10 p.m. 

April 27,'April 27, 
2.15 p.m. 4.10 p.m. 


30 
61 


21 


75 
75 
63 


72 

60 
51 


70 
58 
49 



In another group of cases women who had been exposed to infection 
for varying periods before admission to the lying-in hospitsd were 
attacked after delivery. 



176 



Scarlet Fever. 



(a) An unmarried girl (Cose 138, author's case i) was admitted from 
a mission home on December 26, 1883, and delivered naturally on the 
same day; ninety-eiffht hours after delivery she failed with scarlet 
fever. The nature other illness was not at the time, however, recog- 
nised, and she was allowed to return to the mission home on January 9, 
1884. On January 9 another unmarried girl (Ccise 139, author's case 
iii) was admitted from the same home, was delivered naturally the same 
day, and failed with scarlet fever fifty-nine hours after delivery. During 
December a young woman, F., and her baby had been admitted into 
the home ; on December 18 F. was taken ill, scarlet fever was suspected, 
but no rash appeared, and the suspicion seems to have been discarded, 
and F. was allowed to mix with the other inmates on December 24, two 
days before Case 138 left the home for the hospital. Before this, how- 
ever, this young woman had acted as nurse to F.'s infant. Case 139 
cleaned out F.'s bedroom while F. was ill, and slept in the next room ; 
she was also in contact with Case 138 after her return from the hospital. 
Another girl, Z. {Case 140), was exposed in the same way as Case 123 
to both F. and Case 138 ; Z. left the home for the hospital on January 
13, was delivered that day, and was taken ill on January 19, two days 
after Case 139. 

(&) A certain midwife on January 26, 1884, delivered a personal 
friend, three of whose children were at the time convalescent from 
scarlatina, one of them being in process of desquamation. The mother 
was not affected, and made a good recovery from her confinement. It 
was otherwise with three young unmarried women who were residing 
in the midwife's house expecting their confinement ; they all suffered 
from scarlet fever after admission to the Iving-in hospital at the 
dates shown in the following table. For the five or six days following 
her friend's delivery this midwife had spent the evening in the infected 
house ; she was fetched to bring each of the girls to the hospital when 
taken in labour. On each occasion she accompanied them in a cab, 
and one of them, on the way, she subjected to a vaginal examination to 
make sure that labour had set in. Each of the patients occupied 
separate lying-in wards. Case 141 was admitted on January 29, Case 
142 on January 31, and Case 143 on January 31. Each was delivered 
on the day of admission. 



No of 


case. 


Duration of 

exposure before 

labour. 


Onset of scarlatina. 


Tn this Ust. 


In author's list. 


Aiter delivery. 


After first day of 
exposure. 


ri88 

- 139 
1.140 
fl41 
< 142 
1 148 


• 

1 

• • • 

111 
iv 

V 

vi 


8 days 
28 „ 
28 „ 
3 „ 
6 „ 
6 „ 


98 hours 
59 „ 
4 days 
74 hoars 
97 „ 
124 „ 


12 days 
81 „ 
81 „ 

7 „ 

10 „ 

11 „ 



Dr. Boxall points out that in the cases in this table in which the 
infection was received before labour the periods of incubation are 



Scarlet Feveu 177 

rather longer than in the cases in the preceding table in which infec* 
tion was received after or during labour. 

It may be convenient to add here the facts as to the infants of the 
16 women whose cases are recorded by Dr. Boxall. (The Roman 
numerals are those used by him.) 

Gboup I. — Date and mode of infection in mother unknown 

whether before or after delivery, 
ii. Mother attacked forty-five hours after delivery ; child un- 
affected ; suckled throughout, 
ix. Mother attacked fifty-eight hours affcer delivery; child 
unaffected ; suckled throughout. 

Mother infected before labour. — 
Geotjp II. — Date and mode of infection of mother unknown, 
vii. Died during labour, 
viii. Had scarlet fever first day; died eighth day; suckled 

one day. 
xiii. Unaffected. 

xiv. Unaffected ; suckled for a few days, 
xvi. Still-bom. 

Gbotjp m. — Date and mode of infection of mother known, 
i (Case 138). Unaffected ; suckled throughout, 
iii ( Case 139). Unaffected ; suckled fiffceen days, 
iv (Case 141). Probably had scarlatina. Died on seventh 
day. Death preceded by diarrhoea and vomiting two 
days, and convulsions one day. 
V (Case 142). Unaffected ; suckled till sixth day. 
vi (Case 143). Unaffected ; suckled till eleventh day. 

Gboup IV. — Mother infected during or after labour. 
X (Case 135). Scarlatina about twenty-first day. 
xi (Case 136). Unaffected; suckled two months, 
xii (Case 137). Unaffected ; suckled for seven days. 
xv» Had scarlet fever three weeks after removal to fever hos- 
pital. Suckled. 

Dr. Boxall's conclusions are : 

(a) That infimts kept at the breast are especially prone to scarlatina, 
probabh" from the mere fact of contact with the affected parent, 

(h) That when scarlatina shows itself in the mother during preg- 
nancy the foetus may or may not be affected in wtero» 

(c) That when the mother receives infection shortly before delivery^ 
the infant more frequently escapes, though it may be subsequently 
infected. 



SMALLPOX. 

DB. Mnrcliison, in Ids paper read before ihe Society in 1878^ 
after observing that in none of ibe infections diseases 
does the period during which the poison incnbates appear to 
be fixed, adds, '^ Even in smallpox the latent period is not 
' limited with precision/ as stated by Tronssean/' The cases 
received by the Committee afford evidence of slight variation 
only. The incnbation period when the disease is conveyed by 
inoculation is stated to be seven days, but as in none of the 
cases received by the Committee was the disease acquired 
in this manner, the duration of the latent period after in- 
oculation will not be discussed here. In the tables which 
follow it has been necessary to calculate the period which 
elapsed between exposure and the first appearance of the 
eruption,"^ because in certain cases the date at which the initial 
symptoms appeared was not recorded. 

Incubation Period. 

From Table I, which contains all the cases in which the 
disease was contracted after exposure to infection for a short 
known period, it will be seen that the shortest period of incu- 
bation is shown by Case 59. In this case the period cannot 
have been more than nine days, and the eruption appeared on 
the thirteenth day after the first exposure. The history of 
the exposure in this case is not very fully given, but there 
appears to be no reason to suspect the general accuracy of the 
account. In Cases 78 and 79 the initial symptoms were 
noticed on the tenth day, but the eruption did not appear until 
after thirteen days, a period which must be considered to be 
embraced by the average duration. In Case 74 the eruption 

* When writing of smallpox it appears to be convenient to restrict the term 
^emption ** to the true papule, vesicle, pustule, or pock, using the term ** rash " 
for erythema, purpura, or other efflorescence occurring during the initial illness. 



Smallpox. 



179 



is said to have appeared on the twelfth day^ and it may be 
suggested as possible that some previous communication 
by means of fomites may have been the effective source 
of infection^ although no evidence in that direction was 
obtained. 

Table I. — Oases in which there is evidence that the disease was 
contracted by exposure for a short Tcnown period. 





Interval between ex- 






No. 


posui 


eand 


Circumstances of exposure. 


Condition as to 
vaccination. 


59 


Initial 
symptoms. 


Eraption. 






8 or 9 


12 or 13 


Visited a patient on two days preced- 


Vaccinated. 








ing his death 




74 


10 


12 


Visited a patient on fourth day of 
eraption 


Ditto. 


78 


10 


13 


Visited an infected house and removed 
infected hedding 


Vaccinated in 
infancy. 


79 


10 


13 


Ditto 


Ditto. 


2 


11 


— 


Visited a patient with smallpox 




91 


11 


— 


Visited a town in which smallpox was 


Imperfect 








prevalent 


primary 
vaccination. 


1 


— 


13 


Visited an infected honse 


Vaccinated. 


lU 


11 


14 


In same ward, for fonr hours preceding 


— 








death, with smallpox patient 




76 


11 


14 


Visited a house infected with " chicken- 


Vaccinated. 








pox" 




83 


11 


14 


Visited a patient on third day of erup- 


Vaccinated in 








tion 


infancy. 


10 


12 


14 


Fomites 


— 


61 


12 


14 


Visited a town in which smallpox was 
prevalent 


Vaccinated. 


67 


12 


14 


Saw and touched body of child dead 
of "chicken-pox" 


Bevaccinated. 


82 


12 


14 


Visited a patient on second day of 
eruption 


Vaccinated in 
infancy. 


111 


12 


14 


Slept with a man who had been ex- 
posed for three days 


Ditto. 


114 


12 


^^ 


Visited house in which resided a person 
who had been exposed 


Unvaccinat«d 
infant. 


54 


12 or 13 


^— 


Pregnant woman exposed to patient 
in first week 


^~ 


110 


— 


14 


In contact with a smallpox patient for 
a few moments 


— 


66 


12 or 13 


14 or 15 


— i 


Vaccinated. 


89 


11 


15 


Visited a patient 


Vaccinated in 
infancy. 


81 


13 or 14 


14 or 15 


Two visits to a patient on third and 


Ditto. 




• 




fourth days of rash 


^ 



180 



StuUljpox. 





Ldcrtalbi 


i««.«. 






HoL 


iBHiil 


%wad 




Gonditiaa as to 


67 


13 or 13i 


14 or 141 


Intel view with patient on fonrth and 
fifth days of emption 


Vaccinated in 
in&ney. 


101 


12 


15 or 16 


IHnted an infected hooaein same village 


— 


76 


12 


16 


Interview with smallpox nnrse 


Vaccinated. 


• 

. 1 


13 


16 


Intimate contact with patient on first 
day 


Vaccinated in 
infancy. 


• • 

11 


13 


16 


Visited a patient 


— 


87 


13 


16 


Interview with patiait with omflnent 


Vaccinated in 
in&ncy. 


103 


14 


-^ 


Visited a patient in same village on 
day of initial symptoms 


^^^ 


112 


U 


— 


Brief contact witii infected hedding 


— 


58 


15 


17 


Visited an infected town 


Vaccinated. 


70 


15 


17 


Visited by a patient convalescent from 
«* chicken-pox'* 


Ditto. 


85 16 or 17 


17 or 18 


In an infinnary with a smallpox 


Vaccinated in 








patient 


infancy. 


102 


14 


18 or 19 


Visitedan infected hoosein same village 


— 


56 


20 


23 


Visited by a patient discharged from 
infections hospital 





Cases in which the date at which the exposnre commenced 
is known may possess a certain yalae if they show an nnnsually 
short interval between the beginning of the exposure and the 
onset of the disease. Cases of this kind have been brought 
together in Table 11^ and it will be seen that only two^ or at 
most three, can be quoted as evidence for a period of incuba- 
tion shorter than that usually observed. In Case 4 the 
interval between the commencement of exposure and the 
initial symptoms was only ten days^ but the interest of the 
case is somewhat diminished owing to the date at which the 
eruption began to appear not being mentioned ; the woman 
had just been confined, a circumstance which may have had 
some effect in shortening the period of incubation, and her 
relations with the sufferer from smallpox were very intimate. 
In Case 9 the interval between the commencement of exposure 
and the appearance of the rash was thirteen days, which, as 
already observed^ cannot be considered to be beyond the range 
of average variation; at any rate, the departure is, not suffi- 
ciently wide to call for any special comment. In the other 
case (3) the eruption is said to have appeared ten days after 
the commencement of the exposure, but it seems not impossible 



Smallpox. 



181 



Table U.-^Casesm which eocposure commenced at a known date, 
showing the number of days after comin&ncemsnt of such 
expostire at which the disease began. 





laterral between commenoemeiit of 




ezpofure and 


No. 


J 




Initial lymptoma. 


Eruption. 


3 


_ 


10 


4 


10 


— 


9 




13 


65 


12 


14 


65 


12 


15 


98 


12 


15 


100 


12 


15 


104 


13 


— 


105 


18 


— 


64 


14 


— r 


106 


14 


— - 


12 


^-^ 


16 


13 


— 


16 


68 


14 


17 


95 


15 


— 


80 


15 


17 


84 


15 


17 


72 


16 


— 


96 


16 


— 


107 


16 


— 


77 


17 


20 


71 


18 


20 



that the infection may have been contracted at some earlier 
date^ perhaps by means of fomites. 

Dr. Birdwood, Medical Superintendent of the Smallpox 
Hospital Ships of the Metropolitan Asylum Boards in a 
communication addressed to the Committee expresses the 
opinion that menstruation complicating the initial illness and 
producing lumbar pain may account for some of the supposed 
examples of short incubation periods. '^ Headache/' he 
adds^ ^^ is also a source of error ; most of the patients admitted 
into infectious hospitals are not seen by the reporters until 
the appearance of the eruption has led to the diagnosis of the 
disease^ so that the dates of initial illness are commonly 
' patients' histories.' " 

On the whole^ the evidence submitted to the Committee 
appears to render necessary the admission that the incu* 
bation period of smallpox may be as short as nine days^ 



182 



SmaUpox, 



but affords no support to the opmion tliat it is ever shorter. 
— as shorty for instance^ as five or six dajs^ periods which 
hare been accepted by some authorities.* 

Tabub in.— Oaje9 in which exposure ceased at a known date. 





laterval betve 
apoOT 


maad 


Ho. 


^__SA*  J 


.^ 


97 


9 


_ 


80 


9 


11 


71 


10 


12 


73 


10 


12 


72 


11 


— 


95 


11 


— 


86 


11 


13 


03 


11 


14 


92 


12 




96 


12 


— 


69 


12 


14 


14 to 63 


— 


14 


62 


13 


15 


93 


15 


^ 


94 


16 


^■~ 



A point of greater practical importance in the administra- 
tion of the laws regarding public health is to determine 
whether the true incubation period of smallpox ever much 
exceeds the average which is generally accepted and acted on 

* Dr. Morchiflon writes (Trans,, loc. cit.), " CnrBchmaxui, in hii recent article 
on ' Variola ' (Ziemssen's C^clopadia, Amer. edit., voL ii, 1875, p. 841), remarks 
that the latent period of snudlpox is not so constant as is always maintained. 
In cases where he had heen able to fix it exactly it had certainly been most often 
between ten and thirteen days, but in others it had been as long as foarteen 
days, or as short as from eight to ten days, while in one it was only five days. 
Zuelzer also fonnd the period of incubation in certain (nine) cases of htemor- 
rhagic smaUpox to be only from six to eight days. Lastly, the fact that the 
incubation period of smallpox is far from being fixed was demonstrated by the 
late Dr. Otto Obermeier, in a memoir containing the largest collection of obser- 
Tations on the latent period of smallpox with which I am acquunted" (Vir- 
chow's ArchiOf Bd. liv). Of eighteen cases in which the actual moment of 
infection was determined, — 

In 1 the incubation period was 5 days. 
1 « 6 

3 „ 8 

1 „ 9 

2 „ 10 
6 „ 11 

4 „ 12 
1 „ 18 



n 
if 



ft 



Smallpox* 183 

« 

•*— twelve days. For this purpose we have to consider certain 
cases in Tables I and III. In the cases in Table III the date 
at which exposore to infection ceased is known ; such cases 
may afford evidence of nnnsually long periods of incnbation. 
It is worthy of note, however, that in three only are the facts, 
as reported, incompatible with an incubation period of twelve 
days. These are Cases 62, 93, and 94. 

In Case 62 the interval between the cessation of exposure 
and the initial illness was thirteen days. In Cases 93 and 94 
the patients were seamen on board an infected vessel, and it 
is, of course, very possible that the infection may have been 
contracted from fomites at some date subsequent to the 
removal of the first recognised case. In the very instructive 
epidemic at the North Surrey District Schools, described by 
Dr. F. Wilkinson (Cases 14 to 53), the interval between the 
cessation of exposure and the appearance of the eruption was 
in all the forty cases exactly fourteen days. 

Table I, however, contains ten cases in which the incuba- 
tion period, if the histories can be accepted as accurate, must 
have been distinctly beyond the period usually received. In 
three of these cases (1, 2, and 87) the interval was only one 
day longer than usual, and it may be, as Dr. Murchison 
suggests with regard to one of his own cases, that the period 
might have been less if the thermometer had been used. 
Against this hypothesis, however, must be set the fact that 
the initial symptoms lasted three days, so that the rash did 
not appear until the sixteenth day, a delay which certainly 
seems to point to a prolongation of the period of incubation. 
Objection may be made to Cases 102 and 103 on the ground 
that the persons attacked lived in the same village as the 
patients, and that infection may, therefore, have taken place 
at some date subsequent to the visit to the infected house. 
However improbable this may seem, the possibility cannot be 
denied ; and it will not be safe to found an argument upon 
these cases. The evidence for a period of fourteen days 
afforded by Case 112 is very strong, but perhaps the weightiest 
instance is Case 58, in which a sailor was att'acked fifteen 
days after leaving an infected port ; Case 70 also gives evi- 
dence in favour of a period of fifteen days. In Case 85 the 
circumstances are too involved to afford evidence of first-rate 
value ; and Case 56, which would require us to admit an incu- 
bation period of twenty days, stands entirely by itself, and is 
in other respects exceptional, as will be pointed out below. 



184 SmmUrox. 



Ddkahoh of iBRczEOire PKnon, 



The infectioiiaiiess of smaUpoz b^;]ii8 with the onset of 
the initial symptoms, bat it is not at that period so easily 
contracted as n^ a hUber date. In the great majority of the 
cases here reported the infection was derived from a patient 
who had the rash folly ont, but in afew instances the patient 
was in an earli^ stage. 



Caaes t» whick infection «mu derived from afatiatd 

early stage. 

14 to 53.— Thoe 40 cams derived infection from a cue which 

JBohtcd in whmt mmt have been en eeriy stage of a 
mild attack of TiTioloid. 
eO* — ^In the ward of a hoopitil with a patient from the day 
belbie nntil the daj after the appeerance of hu 
eruption. 
97.— Szpooed during fint three days from initial symptoms. 
101. — Exposed lor short time to patient day after onset of 
initial symptoms, and two or three days before rash. 

On the other hand^ there is some evidence that smallpox 
becomes progressiTely more infections after the date of the 
initial efymptoms. In Case 60 a young woman was exposed 
on the day the initial symptoms b^gan^ and again five and six 
days later ; she had the rash exactly thirteen days after her 
last visit to the infected person^ so that it is probable that 
she was infected on this day, or on the preceding day, and 
not during her earlier interview. In Case 90 a man was much 
with lus son from the beginning of his ilbiess until the second 
day of his rash, when the boy was removed to hospital. Five 
days later the father visited the son in hospital, and fourteen 
days after this visit he had the eruption of smallpox. Again^ 
in Case 77 the person infected was in close relation with a 
patient who was ill with the initial symptoms two days before 
the eruption appeared ; after this date Case 77 ceased to have 
any intimate relation with the case of smallpox, though she 
remained in the same house for five days more, and frequented 
it afterwards; she had the eruption fifteen days after she 
ceased to live in the same house, and no less than twenty 
after the day on which she attended on the patient; it is 
probable, therefore, that she caught the disease not on the 
day on which she was in close relation with the patient 
suffering from initial illness, but at a later date when relations 
were much less close. Again, the dates in Case 68 render it 



Smallpox* 185 

probable that tlie woman did not contract the disease from 
her husband until the second or third day of his eruption. 

Dr. Birdwood states that during the early emptiye stage 
the disease is not particularly inf ectious^ and refers to Case 90 
in support of this ; he points also to the success which has 
been attained in preventing the spread of smallpox by the 
early removal of patients to hospital. 

The same authority also expresses the opinion that the 
period for which infection persists^ after the acute illness has 
passed^ is short. " For some years past/^ he writes, '' I have 
been discharging patients when all the enclosed pocks on the 
soles and palms have been picked over, and all scales fallen 
or washed off ; this period varies from a fortnight to six weeks 
or so. In no single instance within my knowledge has inf ec- 
tion been attributed to a discharged patient. Certainly 
desquamation after smallpox, seems to be not infectious.^' 

The cases reported to the Committee afford no conclusive 
instance of infection derived from a convalescent patient ; if 
the story told as to the mode in which Case 56 was infected 
can be accepted, and the extremely long incubation which 
would have to be admitted militates against the correctness 
of the assumption that all the facts were ascertained, then it 
would afford an instance of infection after convalescence was 
completely established, and after discharging from an in- 
fectious hospital,, and therefore presumably after efficient 
disinfection of fomites.* Cases 11, 70, and the child J. J. 
mentioned in the account of 70, appear to have derived infec- 
tion from a person who had become convalescent. The same 
is probably true of Cases 104 to 107, though in both these 
instances the infection may have been caught from fomites. 

There is abundant evidence that smallpox may be caught 
from cases of the modified disease, the true nature of which 
is only recognised in the light of subsequent events. The 
epidemic at the North Surrey District Schools (see Case 11) 
is an instance in point. Examples of the unfortunate conse- 
quences of confusing smallpox and chicken-pox are afforded 
by Cases 70 and 76. Failure to diagnose a severe case of 

* Upon this point Dr. Birdi^ood observes, *' The assumption that clothes are 
properly disinfected is not warranted. The patient may not be infectious on 
discharge, bnt he may take his wearing apparel oat of pawn a week or so after 
discharge. Patients' friends, knowing all about sanitary regulations, do some- 
times remove moveables immediately the medical man has certified an infections 
disease, and before the patient is removed. Then, again, the existence of an 
extremely modified form of the disease in a young, well-vaccinated member of the 
family may be overlooked ; so that the making up of history is really difficult.*' 



186 



SwuJlpox, 



gmaDpox must be a nmch less common ev^ent^ bat that sach a 
mistake is liable to be made is proved bj Case iiireported by 
Dr. Mnrcliisoii ; it does not appear that in this instance the 
faQnre to make a diagnosis was doe to ignorance or inexpe- 
rience. 

The retention and conYeyance of infection by f omites is 
an event the occasional occurrence of which is well known. 
Dr. Stevenson's case reported below (Case 9) is a good 
example. Cases 78 and 79 are instances in which the infec- 
tion was canght^ apparently from handling the fomitnre^ &c., 
during the process of disinfecting a room which had been 
occupied by a smallpox patient. In Case 112 there was a 
brief contact with infected bedding. In Cases 9^ 76, 110, and 
114 the infection was conveyed to a third person by indi- 
viduals who had been in intimate contact with smallpox 
patients* In the three first-mentioned cases the infection was 
probably carried by f omites, but in the fourth it must appa- 
rently have been retained in the hair of a nurse employed in 
a smallpox hospitaL Dr. Whitelegge* mentions that during 
a single small outbreak in Nottingham he met with five other 
cases clearly traceable to contact with persons who, though 
themselves escaping, were in free communication with small- 
pox patients. The infection may also be contracted by 
visiting a house in which a person has died of smallpox, and 
viewing the body (Case 67, and perhaps 3). 



Table IV . — Cases in which persons were exposed continuously 
during the period of incubation and early illness {at lea^t), 
showing the interval from initial symptoms to initial sym- 
ptoms or eruption. 



No. of caie. 


Fion miiial to 


From initial to 


From eniptiaift to From emptiQii to 


initial. 


enqytioa 


initiaL emption. 


6 


14 








6 


14 


•^ 


— 


— 


7 


19 


— 


— . 


~— 


8 


14 


— 


— 


14 


97 


12 


— 


— 


— . 


109 


— 


13 


-^ 


10 


113 


14 


"~* 


^^^ 


^■" 



* The ftatement is made in his Annual Beport of the Medical Cjfieer of 
MeaUhfor the Borough of Nottingham, 1888, to which he has directed attention. 



Smallpox. 187 



Vaccinia and Vabiola. 

Mr. Frank Colclougli has contributed an interesting note 
founded npon the experience of the Smallpox Hospital Ships 
of the Metropolitan iooard from the time Dr. Birdwood became 
Medical Superintendent. It would appear from this state- 
ment that a very large proportion of persons vaccinated or 
revaccinated successfully at or shortly before the commence- 
ment of exposure to infection escape infection entirely. In 
some instances^ however^ on or about the twelfth day the 
individual suffers from an attack of illness characterised by 
backache^ pyrexia, and other symptoms of fever, and accom- 
panied sometimes by an erythematous rash ; recovery occurs 
in two or three days. This illness is of sufficiently common 
occurrence to have come to be recognised by the staff as a 
kind of ^^acclimatisation fever.'^ In other cases again, in 
addition to backache and malaise, with or without pyrexia, 
a few abortive papules appear. Such cases are capable of 
conveying the infection to susceptible persons (see Cases 117, 
118, and 119). Finally, in a small minority of cases a definite 
attack of modified discrete smallpox occurs. 

When vaccination or revaccination fails to prevent infec- 
tion entirely, it does not appear to have any effect in altering 
the period of incubation. 

The experience at the Smallpox Hospital Ships cannot 
afford any statistical information as to the effect of vaccination 
or revaccination performed after exposure to infection has 
commenced, since only those cases in which the protection 
thus afforded fails to be complete came to the knowledge of 
the staff. The returns, however, do indicate very clearly that 
the course of subsequent smallpox may be, and probably 
commonly is, very favorably influenced by vaccination or 
revaccination performed during the first week, at least, after 
exposure to infection has commenced, and they point to the 
probability that the severity of the subsequent attack is the 
less the earlier vaccination is performed. Case 131 affords 
support to the view that even when performed so late as six 
days before the appearance of the eruption vaccination may 
have some influence in causing the subsequent attack of small- 
pox to be of a mild type. The data, however, are not suffi- 
cient to permit of a discussion of this point, which, moreover, 
lies somewhat beyond the scope of this Report. 



188 8mallp<Wn 



Conclusions* 

(1) The incubation period of smallpox is commonly twelve 
days (from exposure to initial symptoms), but is not very in- 
frequently a day more or a day less. It is occasionally only 
nine or ten days, and sometimes fourteen or perhaps fifteen 
days. 

(2) The period of quarantine ought to be fifteen days ; if 
at the end of that time the person who has been exposed to 
infection shows no signs of indisposition, and presents no 
elevation of temperature, it will be safe to conclude that the 
infection has not been contracted. 

(3) Smallpox is infectious from the onset of the initial 
symptoms, and until all scabs have cleared off, but it is very 
much more infectious during the height of the active stage of 
the disease than during the initial illness, so that isolation at 
the time of the first appearance of the rash may be practised 
with a considerable expectation that the spread of the disease 
will thereby be prevented or diminished. 

(4) The infection can be carried by and retained in 
f omites, and in the hair of a person who has been in intimate 
relations with a smallpox patient. 



Smallpox. 189 



CASES. 

Ccues 1 cmd 2. 
Gommanicated by Dr. Gbobob Bi&dvs, Canterbury, 1878. 

A little girl (Case 1) from the country visited a bouse in Canterbury. 
Slie was only a short time in the house. On the floor abore the floor 
in which she was was a case of smallpox. *' There was no case of 
smallpox in the neighbourhood in which she resided, and she could not 
have had the infection from any other source." The eruption modified 
after vaccination appeared on this little girl on the fourteenth day, 
i. e. thirteen days after the visit to the infected house. 

A clergyman (Case 2), upon one occasion only, visited a patient 
with smallpox. He had initial symptoms on the twelfth day, i, e, eleven 
days after the visit. 

Cases 3 to 6. 
Commnnicated by Dr. F. A. Bbst, Walthamstow. 

A. (Case 3) returned home on February 6 to attend the funeral of 
his father, who had died of smallpox on February 1, 1877. A. was re- 
vaccinated before his return, but did not take, and again on February 7, 
and the arm took fairly well. The eruption appeared on February 16, 
and he ran through a modified attack of smallpox (eruption ten days 
after return home). 

A man returned home on Januarv 8, suffering from confluent 
smallpox. His wife (Caae 4), just connned, nursed him to his death. 
The wife was taken ill on January 18th, ten days after her husband's 
return. 

A woman was taken ill with smallpox on January 29 ; two children 
(Cases 5 and 6) were seized on Februaiy 12, fourteen days after initial 
symptoms in mother, and the husband (Ca>se 7} on February 17, nine- 
teen days. No statement as to isolation. 

CaseS. 

Communicated by Dr. F. M. Evans. 

Mrs. T. had several rigors on November 25, 1877, and the eruption 
on November 28. Mr. T. slept in same bed up to and including Novem- 
ber 29. Mr. T. had a rigor on December 9, fourteen days after 
Mrs. T.'s rigors, and eruption on December 12. No mention of iso- 
lation. 

Cose 9. 
Commnnicated by Dr. A. Stbdhak, Great Bookham. 

A. sat up all night December 12-13 with a man. On December 13 
he returned home to another village, and slept that night in the same 
room as a man, J. T., aged 70. J. T. had eruption of smallpox out on 
December 26, thirteen days after commencement of exposure. 



190 Smallpox. 



Case 10. 

Commnnicated^by Dr. Tho8. Stbvbvbov. 

Mrs. B., landlady of a lodging, went downstairs on December 31, 
1879, to stop a woman who h^i Mg^on to bnm a " dress body " in the 
" copper " mreplace. This dress body had been worn by a girl aged 9, 
who resided in another honse, and was received into hospital on Decem- 
ber 28. The sanitary inspector visited the home on December 29, and 
the parochial officer fumigated the room occupied by the girl with snl- 
phurous acid gas, and heated the bedding, &c., in the disinfectin|^ 
chamber to 25(r^ F. ; the dress body was not heated. On January 12 
Mrs. B. was seen by a medical man at midnight, when she had pyrexia 
and vomiting. On January 14 the smallpox eruption appeared. Initial 
symptom twelve days, rash fourteen days after. 

Cases 11 to 53. 

Commnnicated hy Dr. F. WiLXDrBOir, Lewisham. 

A girl, X (Case 11), at the North Surrey District Schools, who 
belonged to a class of forty who were being taught housework, &c., was 
allowed to go to Kensington to visit her mother who was d)dng of con- 
sumption, and on this occasion met a sister recently laid up with 
smallpox. Fourteen days after (as was subsequently ascertained by 
examination of office book) X. was admitted into the Infirmary : she 
was hardly ill at all, and her card was marked gastric ; but when exa- 
mined more carefolly, after a large number of cases of varioloid had 
occurred, she was found to have three spots " evidently those of ^small- 
pox, one in her hair, one on back, and one on inside of thigh." X., 
while in the Infirmary, occupied a bed between two little boys {Cases 
12 and 13) who had been in the Infirmary for months under treatment 
for acute rickets and glandular disease of the bowel respectively. Six- 
teen days after X.'s admission to the Infirmary these two little boys 
" developed smallpox in its very worst form, and both died." Mean- 
while, during the course of one morning, fourteen days after X. had 
been admitted to the Infirmary (and twenty-eight after her visit to 
Kensington), all the forty members {Cases 14 to 53) of the house- work 
class to which X. belonged were admitted to the Infirmary with what 
the nurse supposed to be chicken-pox, but which Dr. Wilkinson recog- 
nised as smallpox. The fort^ ranged between fourteen and eighteen 
years old. The school contamed 900 children, besides staff ; au were 
vaccinated on the day the forty sickened, and on the two following 
days. 



Case 54. 
Commnnicated by Dr. Ph. Boobbybb. 



F. S., aged twenty-three, married and six months pregnant, was 
exposed to infection from a smallpox patient in the first week on 
January 3, and up to noon on January 4. She had initial symptoms — 
headache, epigastric pain, &c. — on the morning of January 16, after 
7 a.m. (twelve days after cessation, and thirteen days after commence- 
ment of exposure to infection). 



Smallpox. 191 

Cctses 55 cmd 56. 
Communicated by Dr. Abhstbono, M. O. H., Newcastle-on-Tyne. 

Miss S. applied for engagement as assistant matron to the New- 
castle Ferer and Smallpox Hospital on January 5, 1872, during an 
epidemic of smallpox ; she was at the hospital about middaj, and stayed 
a few minutes. She visited the hospital again on January 6, staying 
half an hour. On January 16 she was appointed, and began her duties. 
She was revaccinated on this da^, and on January 21 it was " taking 
well ;" she had a faint cicatrix of infantile yaccination. On January 17, 
the day after commencing her duties in the hospital, she had nausea and 
backache, and on January 20 the first spots of smallpox appeared on 
arms and neck. Eruption discrete ; case mild. Did not know of having 
been exposed to any other source of contagion. Initial symptoms 
twelve days, and eruption fifteen days after first visit to hospital. 

A man was discharged from a smallpox hospital on March 6, 1886, 
travelled thirty miles to Newcastle, and visited his sister's house, re- 
maining two and a half hours. He went away by train, leaving none 
of his clothes or other belongings in Newcastle. No subsequent com- 
munication took place by letter or otherwise previous to A. B. (Case 56) 
falling ill. A. B. began to feel unwell on March 26, twenty days after her 
brother's visit, and on March 29 a sparse eruption of smallpox papules 
appeared. There had not been a case of smallpox in Newcastle prior 
to this for over half a year (last case notified in July, 1885). A. B. had 
not recently been outside of Newcastle, and had not been in contact 
with any other known source of infection. 

Case 57. 

Communicated by Dr. J. Loane, Whitechapel, with additional notes by 

Dr. Birdwood. 

A sailor returned to London from Lisbon, and slept at a certain 
house on February 27. He had been ill since February 20, and the 
eruption of smallpox appeared on him on February 23. On February 
28 he was sent to the hospital ship with confluent smallpox. Everybody 
in the house was revaccinated, with the exception of one man, his 
nephew (Case 57), aged 31 years, vaccinated in infancy, who was in the 
same room with him from about 6.30 p.m. to 7 p.m. on February 27, and 
for about ten minutes at 7 a.m. on February 28. The nephew had the 
initial illness on March 13, in the early morning. The eruption was 
noticed at 7 p.m., March 14, on forehead and forearm. Discrete 
smallpox. The house was disinfected with sulphurous acid gas by the 
sanitary officials. 

Cases 58 to 90. 

Communicated by Dr. Bibdwood, Medical Superintendent of the Smallpox 
Hospital Ships of the Metropolitan Asylums Board. 

Case 58. — H. P., a sailor from Sydney, left Port Said after a stay of 
twelve hours on January 21, 1887, at which date there was smallpox at 
Port Said. He arrived in London on February 5, and was ill with pain 
in legs and back and headache an hour after landing. The eruption 
appeared on February 7, and he was admitted to the hospital ship on 
FebruaiT 11. Initial symptoms appeared fifteen days after leaving 
Port Said. 



192 Smallpox. 

CoMe 59. — K. A. Tisited a man, G. (wbo nickened with smallpoz an 
Maich 16, and died an March 22, 1887), on two accuBJans, Maroh 21 
and 22. K. A. had a laah on the body and pain between the ahonldera 
on March 90, nine dajra after his lint Tisit to the man who died. 
Smallpox eruption appeared on April 3» and H. A. died of oonflnent 
•mal^z on April 12. 

Cote 60. — D. A. J., a joong woman aged 20, ''engaged'* to O., went 
with him to an entertainment on March 16, 1887 (G. first felt ill at this 
entertainment), and visited him on March 21 and 22. She had rigor» 
backache, and headache on April 1, sixteen daja after going to an 
entertainment with G., whom she kissed on parting, and ten days after 
her last Tisit to him on daj of his death. She had rash on April 4. 

CoMe 61. — IL. H., female. Tinted relations at Stockton^on-Teefl^ 
when there was smallpox in the town, on April 22, 1887 (early in May 
smallpox occurred in this fiunily). On May 4 M. H. suffered ftova. 
initial illness (twelTe days after visit to Stockton), and rac^ on May 6. 

CoMe 62. — ^A. H., female, paid a Tisit from AprQ 22 to April 24 to a 
relatiTe in a hospital at Portsmonth, in which hospital were two small- 
pox cases at that time. A. H. had initial illness on May 7 (thirteen 
days after leaving Portsmouth), and smallpox emption on May 9. 

Case 63. — N. G., male, a Spanish ship-steward, was at Seville from 
Jnly 17 to July 23, 1887. He went ashore daily, and knew there was 
''plenty smallpox there." He had headache and pain in back on 
Angust 3, arrived in London on August 4, and had smallpox eruption 
on August 6. Initial symptoms eleven days after leaving Seville. 

Ciue 64. — ^W. Y. (revaccinated six years before), a clerk at the 
docks, met N. G. (previous case) daily between August 4 and 8, went 
with him to a hospital on August 8, and was subsequently to August 4 
engaged on the infected ship daQy. W. Y. had headache and badcache 
on August 18, fourteen days after first meeting N. G., and ten days 
after his admission to smallpox hospitaL Eruption: — ^August 23. — 
*' Slight blush in groin." August 24. — "General all over body.'* 
August 25. — Admitted. 

Case 65. — H. S., a British steward's boy, was at Lisbon from Aug^t 
17 to 20, 1887. He arrived in London on August 25, had headache and 
backache on August 29, and eruption on August 31. Initial symptoms 
twelve days after arrival at, and nine days after departure from losbon. 

Case ^, — A C, female, on October 14 or 15, 1887, went to a rag-shop 
in which had worked a man who was admitted to the smallpox hospitsQ 
ship on October 11. On the same day on the steps of a tramcar she 
was passed by a man who had scabs on his face. A. C. had headache, 
backache, and sore throat on October 27, twelve or thirteen days after 
supposed exposure, and had smallpox eruption on October 29. 

Case 67. — S. A. Y., female, on (Jctober 31, 1887, saw and touched the 
body of a neighbour's child said to be dead of chicken-pox. She had 
headache^ sore throat, and malaise on November 12, twelve days after 
touching child, and smallpox eruption on November 14. 

Case 68. — A. S., female, aged 31. Her husband returned from Bar- 
celona on January 5, 1888. He had had initial sjrmptoms on January 4, 
the eruption appeared on January 6, and he was removed to hospital 
on January 10. A. S. had initial illness on January 19, and eruption 
on January 22. A. S. had initial illness fourteen days after husband's 
return. 

Case 69.— T. S., male, from January 20 to January 22, 1888, was in 



Smallpox. 198. 

the ward of a hospital with a patient who had smallpox eruption on 
January 21. T. S. had ri^or and pains in the back on February 3» 
fourteen days after beginning and twelve days after end of exposure to 
infector, and eruption on February 5. 

A girl who had been staying at an uncle's, and there had an illness 
diagnosed chicken-pox, arrived home on or about January 23, 1888. 
Her brother, J. J., had convulsions and vomiting on February 2, and 
smallpox eruption on February 5. R. J., female (vaccinated) aged 21 
(Case 70), was visited by J. J.'s sister on January 28. R. J, had headache 
on February 12, fifteen days after the visit, and the smallpox eruption 
on February 14. 

Case 71. — J. B., female (vaccinated) aged 40, attended a smallpox 
patient at home from February 17 to February 25, 1888. J. B. had 
Backache on March 6, eighteen days after commencement, and ten days 
after the end of her attendance on the patient. Bash on March 8. 

Ca^se 72. — ^A. W., female (vaccinated) aged 29, visited friends at 
Burnley, where her young man's sister had smallpox at this time, from 
February 25 to March 1, 1888. A. W. had vomiting and backache 
on March 12, sixteen days after arriving at, and eleven days after 
leaving Burnley. Eruption March 13. 

Case 73. — P. F., male (vaccinated) aged 44, left Milan, where there 
was smallpox, on April 4, 1888. He had headache, backache, and sore 
throat on April 14 (ten days after leaving Milan), smallpox eruption on 
April 16, and died on April 24. 

Case 74. — H. W., male (vaccinated) aged 44, on April 4, 1888,. 
from 7 to 9 p.m. visited his brother and sister«in-law. The sister-in- 
law had smallpox eruption on April 1, the brother on April 6. H. W. 
had backache on the morning of April 14 (ten days after the visit), and 
had smallpox rash on April 16. 

Cflwe 75. — J. 0., female (vaccinated) aeed 39, on June 7, 1888, from 
8.30 p.m. to a little after 9 p.m. visited a house in which a young man 
was very ill with ** chicken-pox." On June 18 J. C. had headache and 
backache (eleven days after the visit), and early on the morning of 
June 21 she had smallpox eruption. 

Case 76. — K. M., female aged 19, was in the society of a smallpox 
nurse who had bathed, changed her clothes, and brushed — but not, as 
was usual, washed — her hair, from 11 p.m. on July 16 to 6 a.m. on 
July 17. On July 28, in the evening, she had initial symptoms, twelve- 
days after commencement of exposure. Smallpox eruption on August 1. 

A nun arrived in London from Paris on October 22, 1889. She was- 
feeling ill at that time. On October 24 the eruption of smallpox was 
noticed. A probationer (Case 77), aged 21 years, who fancied she had 
been vaccinated in infancy, but had no scars, attended to the nun 
*' the greater part of the day " on October 22. She remained in the 
convent up to October 27. After that she was sent out to nurse a 
patient, but returned to the convent daily for dinner till November 8, 
when she had initial illness. She had the eruption (discrete) on 
November 11. 

A man arrived in London from Gijon, in Spain, on March 3, 1890. 
He had the initial illness of smallpox on March 5, the eruption on 
March 9. Two men employed bv the Yestry to disinfect his oedding, 
&c., were at the infected house for about half an hour at 11 a.m. on 
March 13. One of these men (Case 78), aged 23, vaccinated in infancy, 
had vomiting March 23, pain in the back on March 24, and rash on the^ 

N 



194 Smallpox. 

hips on Marcli 25. The pock eruption (discrete) was first noticed on 
the back on March 26, early in the morning. 

The other man {Case 79), aged 35, vaccinated in infancy, was sleepy 
and cold on March 23, and complained of backache and aching limbs 
on March 24. The eruption (discrete) was first noticed on March 26, 
twelve pocks on forehead. 

Case 80. — A woman aged 35, vaccinated in infancy, attended a 
smallpox patient who had initial illness on May 11, and eruption on 
May l4i, 1890, from May 13 to 19. Case 81 had initial illness on May 
28 in the morning, and the eruption (discrete) on the wrists on. 
May 30. 

Case 81. — A man aged 24, vaccinated in infancy, visited the same 
patient on May 16 and 17. He had initial illness, headache, drowsiness, 
pains in back and ** stomach," on May 30, in the morning. On May 31 
he had the eruption (discrete) on the arms and face. 

Ca>se 82. — ^A boy aged 6, vaccinated in infancy, on May 18, 1890, 
visited a patient who had had initial illness on May 15, and eruption 
on May 17. The boy had the initial illness on May 30, and the eruption 
(discrete) on June 1. 

Case 83. — ^A woman aged 19, vaccinated in infancy, visited the same 
patient on May 19. She had the initial illness on May 30, and the 
eruption (discrete) on June 2. 

Case 84. — A man aged 18, vaccinated in infancy, was in hospital at 
Lisbon from December 15 to 24, 1890, with " typhoid." Whilst there 
he heard there was a smallpox patient in the hospital. He had the 
initial illness (giddy) on December 30, 1890, and the eruption appeared 
on the abdomen on January 1, 1891. 

Cases 85 and 86. — A smallpox patient went to an infirmary on Feb- 
ruary 24, and was removed on February 25, 1891. A patient in that 
infirmary, aged 47 (Case 85), vaccinated in infancy, had the initial 
illness (sleepy) on March 13, and the eruption (discrete) on March 14, 
He was removed on March 16. Another patient {Case 86) occupied a 
bed in the same ward as the previous case. He had the initial illness, 
headache and " like knives in back," on March 27. A rash appeared 
on the same day, and papules on the forehead on March 29. He died 
of confluent smallpox. 

Case 87. — A potman, aged 29, vaccinated in infancy, served a cus- 
tomer who had confluent smallpox on March 16, 1891, and was a long 
time with him. The potman had the initial illness on March 29, and 
the eruption on April 1. 

Case 88. Concwrrent smallpox and vaccination, — ^A baby, aged 11 
months, was vaccinated successfully on April 6 on arrival at the hos- 
pital, and returned to her home on the following morning. She had 
the initial illness (convulsions) on April 17, and the eruption (discrete) 
on April 19. 

Case 89. — A woman aged 43, vaccinated in infancy, visited her 
daughter ill of smallpox at home on April 17, She had initial illness 
on April 28, and the eruption on May 2, 1891. 

Case 90. — A boy aged 7 years, was ill of smallpox on May 7, and 
bad the eruption on Mav 9, 1891. He was removed to hospital on 
May 11. " His father {Case 90) was with him during his illness at 
home. He was not infected then. The father visited his son in hos* 
pital on May 16, between 3 and 5 p.m." He had the initial illness on 
May 28, and the eruption (discrete) on May 29. 



Smallpox. 195 

Cases 91 to 97. 
Communicated by Dr. Ed. Walpobd, M. 0. H., Cardiff. 

Case 91. — J. P., aged 46, residing at Cardiff, where at that time there 
were no cases of smallpox, visited Bristol on December 29, 1887, at 
which date smallpox was prevalent in that city. He did not, to his 
knowledge, come in contact with any infected person. He had the first 
symptoms of smallpox on January 9, 1888, eleven days after visiting 
Bristol, and subsequently a confluent attack ending in recovery. 
Primary vaccination marks imperfect ; not revaccinated. 

Coses 92 to 94. — H. M., aged 30 {Case 92), was a sailor on board 
ss. J. O. H. ; another sailor was landed at Antwerp from this steamship 
on May 12. H. M. had the first symptoms on May 24, twelve days 
after the other sailor was landed at Antwerp. He recovered. Imper- 
fect primary vaccination. W. Q., aged 28 (Ca^e 93), a sailor on the 
same steamship, had the first symptoms on May 27, fifteen days after 
the sailor was landed at Antwerp. He recovered. Imperfect primary 
vaccination. Ck., aged 20 {Case 94), also a sailor on the same steam- 
ship, had the first symptoms on May 28, sixteen days after the sailor 
was landed at Antwerp. He recovered. Imperfect primary vaccina- 
tion. As the source of infection in the first case was not discovered, 
and as it is not impossible some bedding or clothing may have been 
left behind, much importance cannot be attached to the long periods 
shown by Oases 93 and 94. 

Case 95. — J. P., aged 30, was a sailor on ss. L — n, which was at 
Barcelona, where smallpox was prevalent, from October 1 to October 5. 
J. P. was ashore during this period. He had initial symptoms on 
October 16, eleven days after leaving Barcelona, fifteen after arriving 
there. He recovered. He had never been vaccinated. 

Cose 96. — M. J., aged 30, a negro, was exposed to smallpox infection 
while convalescent from scarlatina in a hospital shed from October 23, 
when J. P. was admitted, until October 27, when M. J. was discharged. 
M. J. had first symptoms of smallpox on November 8, twelve days after 
'discharge from hospital. Recovered. Never vaccinated. 

Case 97. — J. W., aged 16, who was exposed between November 12 
and 15 to infection (by a youth who had initial symptoms on Novem- 
ber 12), had initial symptoms on November 24, twelve days after infector 
-developed first symptoms. He died. Imperfect primary vaccination. 

Cases 98 to 103. 

Communicated by Dr. Wm. Bobinson, Stanhope, Darlington. 

Epidemic in a village. — The epidemic was started by a woman who 
-came from Toft Hill ; she infected her brother, brother's wife, and a 
man lodging in their house. The lodger, G. A., was covered with fully 
developed pustules, many confluent, when first seen by Dr. Robinson 
on January 28, 1885. The brother, J. S., was taken ill on January 23 
with acute pleurisy; the temperature fell on January 24, but rose 
again, and on January 28 the rash began to appear. Mrs. S. had two 
or three fully developed vesicles on January 26. These cases recovered, 
and the house was disinfected on Pebruary 23. Mrs. J. P. {Case 98), 
who lived next door to J. S., was in J. S.'s house on January 26 and on 
JTanuary 28. She had initial symptoms on Pebruary 7 (twelve days 



196 Smallpox. 

after first yisit), and rasli on Febmary 10 or 11 . Her hnsband {Ccue 5)9) 
had initial symptoms on Febroary 21 or 22 (fourteen or fifteen days after 
bis wife began), and died March 9. IJnTaocinated. J. L.'s daughter 
(Ca»e 100), who lired next door to J. S. on the other side, was in J. S/s 
boose on Jannary 26 and 28. She had mitial symptoms on Febroary 7, 
and rash on Febroary 10 or 11. W. G. (Case 101), who lired a qoariker 
of a mile from J. S., was at J. S.'s boose on Janoary 26 only. He had 
initial symptoms on Febroaiy 7, and rash on Febroary 10 or 11. 
Initial symptoms twelve days after single ezposore. T. H (Case 102) 
lived a qoarter of a mile from J. S. ; was at J. S.'s boose on Janoary 26- 
onl^. He had initial symptoms on Febroary 9, f oorteen days aft^r the 
visit to J. S.'s boose. On Febroary 11 he came oot in a red rash all 
over the tronk like that of scarlet fever, and two or three days later 
the characteristic spots began to appear. Mrs. B.'s daughter {Ccue 103), 
who lived 100 yards or more from J. S.'s boose, and in another street,, 
visited Mrs. J. P. (98) on Febroary 8. The day after Mrs. J. P. had 
initial symptoms, and two or three days before her rash. Mrs. B.'s 
daoghter had initial symptoms on Febroary 22 (foorteen days after 
the visit to Mrs. J. P., which was her only ezposore to infection). 

Cases 104 to 107. 

Commimicated by Sir Gbobob Buchakaf, M.D., F.B.S., late Medical 

Officer to the Local (Jovernment Board. 

In Dr. Airy's Report to the L. G. B. on the sanitary state of Holl^ 
Joly 26, 1882, Br. Mason, M. O. H., gives the following facts as to an 
ootbreak of smallpox in the Infections Disease Hospital, a wooden 
stroctore with a brick annexe osed for smallpox patients. At the 
beginning of Janoary, 1882, the hospital contained fifty patients, nine 
sonering from smallpox and the remainder from scarlet fever. On 
Janoary 2 the smallpox patients began to ose a troogh closet, to reach 
which they had to traverse the lobby which connected the brick annexe 
with the main boilding ; at this time sixteen patients (eleven adolts- 
and five children) convalescent from scarlet fever were osing another 
troogh closet on the opposite side of the lobby. These closets were 
insofficiently floshed, and their ontrapped soil-pipes were onited onder 
a washhoose attached ootside the boflding; the pipes had often 
been blocked, and the closets offensive. Of the sixteen convalescent- 
scarlet fever patients who osed the troogh closet seven contracted 
smallpox, viz. two cases (Cases 104, 105) on Janoary 15, thirteen days 
after the smallpox patients began to ose the closet referred to, one 
(Case 106) on January 16 (foorteen days), one (Case 107) on Janoary 18 
(sixteen days). Three other patients who began osing the troogh closet 
some days later than those first attacked sickened on Janoary 23, 
27, and 29 respectively. Among the remaining twenty-five patients 
who were not yet convalescent, and osed other appliances, no cases of 
smallpox occurred. 

Cases 108 to 114. 

Commimicated by Dr. Abthttb Whitblbogb, M. O. H. West Riding (formerly 

M. O. H. Nottingham). 

From January, 1886, when the last case of smallpox was discharged 
from hospital, down to December, 1887, there had been no case of small- 
pox in or near Nottingham. A family of music hall " artistes " came 



S^mallpox, 197 

from Aldersliot to Nottingham on December 5, 1887, and took np their 
•quarters at a private lodging-house. The family consisted of lather, 
mother, a girl aged twelve years, and a boy aged eight. The parents 
had been vaccinated in infancy, but the children were unvaccinated. 
Smallpox had been unknown in Aldershot for two years previously, 
and no case occurred after their departure. They travelled direct to 
Nottingham. They were probably infected on the journey, but could 
remember nothing suspicious in the appearance of any of their fellow- 
travellers. Twelve days after their arrival, however, that is on Decem- 
ber 16, the girl {Case 108) was taken ill, and the eruption of smallpox 
appeared on December 19. No medical advice was sought. The patient, 
who underwent a rather sharp attack of discrete smallpox, was kept in 
an upper room, nominally visited only by her parents and the landlady. 
The nature of the disease was successfully concealed from the other 
lodgers until December 27, the eighth day of eruption. Upon the evening 
•of that day Dr. Whitelegge was informed of the case, and had the child 
removed to hospital. The other inmates were warned of the danger they 
had incurred, and all were successfully vaccinated or revaccinated, and 
among the rest an infant of three months. The giiTs brother {Case 109) 
had eruption of (subsequently confluent) smallpox on December 29. 
This boy was taken ill on December 27 ; he was probably infected at the 
very onset of his sister's illness. There was no other source of infection 
in the town or adjacent country at this time. Another girl living in the 
house, successfully revaccinated on December 28, had a modified erup- 
tion on January 6. 

A girl {Case 110) came into contact with a smallpox patient for a 
few moments at a house where she was calling. Fourteen days after 
this {i. e. on the fifteenth day), the only known exposure, she had a 
43light eruption of modified smallpox. A man whose child was lying ill 
with smallpox left his home on the disease bein^ diagnosed on the third 
•day of eruption, and slept one night with a &iend {Case 111). The 
latter, a man vaccinated in infancy, was taken ill twelve days later {i, e. 
on the thirteenth day), and the eruption appeared in forty-eight hours 
more. At least five other cases were clearly traceable to contact with 
persons who, though themselves escaping, were in free communication 
with smallpox patients. 

On February 28, 1888, a boy (Case 112), aged 10, broke through the 
-cordon made by the sanitary inspector and his assistant, who were 
destroying bedding infected by a case of smallpox which had ended 
fatally on February 25. The boy was immediately driven away, but 
on March 13 he sickened with smallpox. He was not removed to hos- 
pital, but attempts made at isolation within household. On March 27 
an unvaccinated baby {Case 113) was taken ill with smallpox, and on 
April 4 the father, vaccinated in infancy, was attacked with smallpox 
(Normanton, Yorkshire). 

On February 5, 1888, an unvaccinated infant, aged 7 weeks {Case 114), 

^as taken out to tea with some friends, one of whom had some weeks 

' previously come from her home near Sheffield, where one of her children 

had died from smallpox. On February 17 the infant sickened with 

smallpox, subsequently confluent (Altofts> Yorkshire). 



198' Smallpox. 

Communicated to the Society in 1878 by the late Dr. Muschisok. 

" Case I. — On January 9, 1877, Miss L., aged 3, with tliree good vac* 
cination marks, sat on the knee of her aunt, Miss S., who was then 
suffering from headache and febrile symptoms, and was in the first day 
of what proved to be a typical attack of varioloid. After this Miss L. 
went home, and did not visit the house of her aunt again ; nor was she 
in any other known way exposed to the poison of smallpox. On 
January 22 she became cross, lost her appetite, and had fever ; and on 
the 25th a few variolous papules appeared. 

" Here the period of incubation was thirteen days. Possibly, had 
the thermometer been used, it might have been a day less. 

" Case II. — James A., aged 22, was admitted into the London Fever 
Hospital on February 20, 1868, ill two days. His attack turned out to 
be one of varioloid. On February 5 he had visited a friend in White- 
chapel suffering from the smallpox, and on February 18 he was taken 
ill with fever, headache, and lumbar pain, but no vomiting. On Feb- 
ruary 21 the papules of smallpox appeared. 

** Here also the incubation period was thirteen days. 

" Ca^se III. — On September 10, 1864, Eliza P., aged 27, was admitted 
into the London Fever Hospital on the fifth day of an attack of variola 
hsemon'hagica, and died at 10 p.m., four hours after admission. There 
were no characteristic papules, and the case was mistaken for one of 
malignant scarlatina, and placed in the scarlet fever ward. On Sep- 
tember 21, eleven days afterwards, Ruth 0., aged 21, who was recover- 
ing from an attack of scarlet fever in the same ward, having been 
admitted on September 5, on the third day of the disease, was seized 
with the premonitory symptoms of variola, the eruption of which ap- 
peared on September 24. She was desquamating freely when the 
smallpox set in. 

'* In this case the incubation period was eleven days." 



A Note on Vaccinia and Variola. 

Communicated by W. Fbank CoIiClough, B.A.Cantab., M.B.C.S., L.R.C.P.Lond.^ 
Assistant Medical Officer, Hospital Ships, Metropolitan Asylums Board. 

Thb influence of recent successful vaccination in modifying small- 
pox varies, and its results may be classified as follows. 

(a) Complete immunity. 

The large number of persons engaged at the hospital ships are all 
revaccinated at the time of joining, and do not suffer from any form of 
definite variolous illness. Mr. Moule, the steward, has been kind 
enough to obtain from the wages book the numbers of the staff em-- 
ployed from June 10, 1884, when Dr. Birdwood joined the ships as- 
Medical Superintendent, to August 27, 1892, and these are — 

Men . . . . .369 

Women . . . . .323 

692 



Note on Vaccinia and Variola* 199 

This number is exclusive of principal officers, assistant medical 
officers, and contractor's men who have been employed from time to time. 

In Dr. Bird wood's annual report for 1884 he gives details of four 
cases of smallpox among the staff. Two were ill before he joined the 
ships, namely, on May 26 and June 8 respectively. The others were — 

Case 115. — A. M. G., ward-maid, joined July 7, 1884. Vaccinated 
July 8, and again on July 15, partially successful ; she had only a few 
spots. 

Case 116.— G. W., stoker, called on "Endymion" October 21, 1884, for 
employment, and was engaged on October 24. He was vaccinated on 
October 24 (failed) and again on October 31 (successful). Initial sym- 
ptoms were noticed on November 3, and the eruption on November 5, 
1884. He had modified confluent smallpox. 

A fifth case was that of Nurse W. {Case 122), the details of which 
are given later. 

G. W. is clearly a case of concurrent smallpox and vaccination, but 
no details at that time were given in the case-books. 

Therefore in eight years and two ninths more than 692 persons have 
been constantly exposed to infection, and only 3 definite cases of smallpox 
have occurred among them. 

(h) Smallpox without pochs* 

In some instances, although the vaccination is successfiil, yet on or 
about the twelfth day after exposure to smallpox infection a rise in 
temperature to 38° 0. or 39° 0. (i. e. from about 100° F. to 102° F.), with 
backache, anorexia, pallor, constipation, and occasionally a rash or 
erythema, occurs. In two or three days these patients quite recover, and 
the condition is so common that it is recognised by the staff as a sort 
of acclimatisation fever. 

Dr. Birdwood's present method is to vaccinate every member of the 
staff, on joining, in one place, and the individual is kept to the shore 
houses or to the " Endymion " until the vaccination has undoubtedly 
taken : if the vaccination is unsuccessfiil, it is repeated on the third or 
fourth day, and again if necessary at the same interval ; after this third 
vaccination the ordinary duty, whatever it may be, is permitted. 

(c) Abortive papular stage. 

Patients admitted with a wrong diagnosis and members of the staff 
sometimes have a few small papules on the fourteenth day or there- 
abouts after exposure to infection, but these papules do not advance 
beyond that stage ; good instances are the following : 

Cases 117 and 118. — Two patients (brother and sister) — M. S., SBt. H, 
female ; J. S., sat. 3, male — ^were admitted on June 16, 1892. The erup- 
tion in both cases had appeared on June 15, and no history of initial 
illness was obtainable. The diagnosis on admission was chicleen-pox. 
They were both revaccinated at once, and again on June 22 ; both failed. 
They were isolated, and no suspicious symptoms occurred until those 
recorded in the following notes : — M. S., June 27. — " Some papules on 
face and a few on arms, not shotty, very little raised. T. normal ; 
child peevish; no initial symptoms." J. S., July 6.— "Drowsy during 
Afternoon. At 10 P.M. crying out, and limbs occasionally twitching ; 



200 'Note on Vaccinia and Variola. 

headache, flashed. T. 105° F. July 7. — Panctate rose rash on legs ; 
three small papules on face, apparently new ; T. 101'' F. " Garboiie 
soap eruption." 

Both patients were discharged apparently well on July 8, 1892, the 
temperature being normal. Dr. Bii'dwood, at the time of discharge^ 
went very carefully over these two patients, and found no cause to 
prevent their leaving ; he was not able to make up his mind as to the 
cause of J. S.'s "malaise;" thought of smallpox without pocks, but 
finally dismissed that idea. 

Case 119. — On July 31, 1892, their mother, est. 25, was admitted; 
but could give no source of infection. She had been vaccinated in 
infancy (three scars, area *52 sq. in.), not re vaccinated. She had the 
initial illness on July 24, 1892, and eruption on July 28 early, and was 
admitted to the South-Eastem Fever Hospital on July 30. She had a 
severe attack of discrete smallpox. 

The probability is that J. S. at the time of discharge was suffering 
from smallpox, wluch reached the abortive papular stage and infected 
his mother. 

(d) Discrete smcdlpox extremely modified. 

Case 143 (see Table) must have been infected about three weeks after 
successful vaccination ; she had a discrete attack. Ca^e 115 is an ex- 
ample of a mild discrete attack in a patient vaccinated, presumably, at 
the time exposure began. The influence of recent partially successful 
vaccination is well shown in the following case. 

Case 120. — E. P., female, SBt. 50, was admitted to the hospital ships 
on August 2, 1892 ; she had been vaccinated in infancy, and showed 
three scars ; revaccinated when about thirty years old (failed), and 
again on July 18, 1892. The patient stated that her medical man was 
satisfied with the result of the vaccination, and that she had some itching 
and uncomfortable sensations about her arm some days after the re- 
vaccination. 

On admission there was the merest traces of pigmentation at the 
three places ; on her discharge on August 27 there was no trace what- 
ever of revaccination. Her history was that she was infected by her 
husband, who was admitted on July 17, 1892, and died of confluent 
smallpox on July 23, 1892. His eruption appeared on July 14 in the 
afternoon, and the patient nursed him until about 9 o'clock in the 
evening on July 16, when he was removed to S.E. Fever Hospital; 
and she also slept with him for the two nights after the appearance of 
the eruption. She had, therefore, been constantly in his company for 
over two days after the eruption, and also visited him on the ships on 
July 20, when I myself saw the revaccination places. With this ex- 
posure it would be quite justifiable to expect that she would have had, 
if not a confluent, at all events a severe discrete attack. Her eruption 
appeared on July 29, and on August 2 it was pustular and very dis- 
crete, there being only seven pocks on the face. It rapidly modified, 
and presented the typical features of variola modified by vaccination. 
She was not treated with our usual remedies, 01. Menthol and Pulv. 
Oretffi Aromat., but I gave her a mixture of dilute nitro-hydrochloric 
acid, simply as a placebo. 

Case 121. — E. P.'s landlady, Mrs. F., had seen Mrs. P.'s husband once 
or twice from the door only of his room during his eruption. She was 



Note on Vg^cciriid and Variola. 201 

revaccinated at the same time as Mrs. P., with just the same result^ 
not completely successful. She attended to Mrs. P. before her removal 
to the S.E. Fever Hospital on August 1, and was thus exposed for 
■about three and a half days to the eruptive state. She had never had 
smallpox, and had been vaccinated in infancy only.* 

Further, recent vaccination, although unsuccessful, seems to exercise 
3, modifying influence, as the following case shows. 

Case 122. — Nurse W., SBt. 33, vaccinated in infancy, was revaccinated 
unsuccessfully on June 9, 13, and 17, 1892. She came to the hos- 
pital ships on June 9, 1892, and went on duty on June 17, 1892. The 
-eruption of a slight attack of discrete smallpox, which modified, appeared 
on June 27. 

Dr. Birdwood holds that if well-marked papulation is produced at 
the site of the vaccination, there is probably protection. The case 
E. P. seems to be a good instance of the modifying effect, for she was 
•admitted in the absence of Dr. Birdwoo<l, and the appearance of her 
arm on August 2 appeared typical of vaccination taking, up to the 
formation of a papule and then aborting. It had an exactly similar 
appearance to the arm of an assistant medical officer whom I had ample 
opportunity of examining day by day. He was revaccinated on the 
morning of his joining the ships by a medical friend in three places ; 
the following are my notes of his case. 

Case 123. — Revaccinated on a Friday morning at 9.30. On Saturday, 
10 P.M., a small ** angry " areola round each vaccination place. On Sun- 
day, 10 P.M., three places papular, not disappearing on pressure, red, 
-and dark red at centre ; measurements of areolsB 5 mm. in diameter. 
On Monday, 10 p.m., no change. On Tuesday, 8 a.m., commencing to 
disappear. He was revaccinated again that morning in one place 
(fourth day), and then went on duty. The second attempt was most 
43uccessful ; there was considerable swelling of the axillary glands ; the 
arm itself was swollen and angry-looking, with lymphatics well marked 
out in inflammatory streaks ; on the fifth day of the second revaccination 
there were five small vesicles ; they aborted on the sixth day and never 
became confluent. On the twelfth day after going on duty he became 
^'very seedy," with pallor, anorexia, slight backache, headache, and 
general malaise ; after a smart purge, and a long drive in the country 
on the next day, he quite recovered. 

In this case there seems to be no doubt that the first revaccination 
reaching the papular stage and then aborting, together with the second 
revaccination reaching an early vesicular stage and then aborting, 
xtfforded protection ; but that he suffered from " smallpox without the 
pocks" is also, I think, certain. 

Dr. Birdwood, in his article " A Theory of Smallpox " in the Ghiy's 
Hospital Reports for 1891, says on p. 105, when referring to the succes- 
sive crops noticed both in smallpox and in cases of successive vaccina- 
tions ; " Similarly vaccination after smallpox infection may result in a 
pock if done at any time preceding vesiculation." In the few instances, 
however, in which I have revaccinated patients on their admission, 
when the eruption has been in the macular and papular stages, the re- 
Taccination has failed. The reports of over fifty cases of revaccina- 
tion (taken from the case-books) in various stages of the eruption 

* This case seems te me to be an example of protection dae to partially suc- 
<sessf nl vaccination. 



202 Note on Vaccinia and Variola* 

coincide with my few instances. Vaccination performed at any time 
during the incubation period may succeed; and this is true even 
during the initial illness (see summary of tabulated cases) ; but the bulk 
of the evidence that I have been able to gather is against the opinion 
that vaccination will succeed if done when the eruption has appeared. 
I can only find one case, namely, Case 124 in the tabulated list. 

The modifying influence of vaccination within three years is — (a) 
Slight amount of eruption, therefore discrete smallpox, (h) Early 
maturity of the pock, i. e, pustulation on the third or fourth day of the 
eruption, instead of, as Dr. Birdwood teaches, from the eighth to the 
twelfth day in a typical unmodified case, (c) Defective development 
of the pock, and a great tendency to abort, in diameter 1 or 2 mm^ 
instead of 4 or 5 mm. {d) There is also a marked difference in the tint 
of the areolfiB ; it approaches the peculiar red of " boiled salt beef." In 
a fair number of cases I have been able to predict correctly, from this, 
peculiar colour alone, that modification would take place ; but it is 
more frequently present in cases which are modified owing to remote 
vaccination, when the other characteristics of modification are less 
marked. 

The modifying influence of remote vaccination, i, e, after seven years 
is most difficmt to estimate, since smallpox is at times modified in the 
unvaccinated, and it may be unmodified in the vaccinated. 

As a general rule, the modifying influence is gradually lost from the 
third to the seventh year, and frequently does not exist after the latter 
period. 

In Dr. Birdwood's opinion, all persons exposed to the infection of 
smallpox should be revacciuated, unless such persons have been suc-^ 
cessfcdly vaccinated within the preceding two years. 



TABLES OF CONCUERENT VACCINIA 

AND VAEIOLA. 



Concurrent Vaccinia and Variola. 



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Concurrent Vaccinia and Variola. 211 

Snmmarising these twenty-two tabulated cases, there are — ^Four 
cases of confluent smallpox: — Yaccinated on the day of eruption, one 
{Case 124). Yaccinated one day before the eruption, two {Cases 125 
and 141). Yaccinated two days before the eruption, one {Case 136). 

Fifteen cases of discrete smallpox: — ^Yaccinated thirteen days before 
eruption, two {Cases 139 probably, and 145). Yaccinated twelve days 
before eruption, one {Case 130). Yaccinated eleven days before erup- 
tion, one {Case 135). Yaccinated nine days before eruption, two 
{Cases 126 and 128). Yaccinated eight days before eruption, two 
{Cases 133 and 140). Yaccinated seven days before eruption, three 
{Cases 127, 137, and 142). Yaccinated six days before eruption, two 
{Cases 131 and 134). Yaccinated four days before eruption, one 
{Case 132). Yaccinated three days before eruption, one {Case 129). 

Th^ number of cases is obviously not sufficient to make any general- 
isation upon, but the extremely mild attacks of smallpox which the 
reports state that Cases 139 and 145 had are suggestive. 

In two cases (138 and 144), the data are insufficient. 

One case (143) must have caught smallpox about three weeks after 
successful vaccination. 



VARICELLA. 

THE incubation period of varicella is distinctly longer than 
that of smallpox^ but it is often not easy to say whether 
any initial symptoms have been present;. the eruption^ as is 
well known, comes out in successive crops, usually on three 
succeeding days, and the onset of the disease must, as a rule^ 
be reckoned to coincide with the appearance of the first spots. 

Incubation Period. 

In his paper in the Transactions already quoted. Dr. 
Murchison stated that he had notes of only one case show- 
ing the incubation period of varicella, and that in that case 
it was eleven days; he pointed out that this period was 
shorter than that usually assigned, Thomas giving thirteen to 
seventeen days, and Trousseau fifteen to twenty-seven days.* 

The cases received by the Committee are few in number, 
and not many of them will satisfy a rigid examination. The 
cases in which the exposure to infection was for a known 
short period have been collected in Table I ; they are only 
six in number. 

Table I. — Cases in which the exposure wa>s for a known short 

period. 

Interval to 

J- 



No. of Initial Rash. 

eaie. ■ymptoma. 

26 13 In the company of a patient day after return 

to school. 

12 14 In the company of a patient for two hours 

day of return to school. 

13 14 In same house at school for one night. 
30 14 or 16 16 or 17 Visited by a nurse. 

14 19 In same house at school for one night. 
16 19 

* Dr. Murchison adds, '* When varicella is produced by inoculation the 
incubation period appears to be shorter than when the disease is contracted in 
the ordinary way, just as in the case of smallpox and measles. Thus, of ten 
cases in which Froiessor Steiner of Prague inoculated the contents of the vesicle 
of variceUa, eight were successful. Varicella, and not variola, was always pro- 
duced, and previous vaccination had no influence whatever on the result. In all 
of the eight children the period of incubation was eight days {Brit. Med, Joum,, 
May 8th, 1876, p. 610)." 



Varicella, 21S 

The longest interval between exposure and the first appear- 
ance of the rash was nineteen days^ and the shortest thirteen 
days. In four instances the exposure began at a known date 
and continued thereafter, either until the eruption appeared^ 
or for a large part of that interval ; these cases are — 

Case 5. First symptoms 14, and eruption 16 days after commencement 

of exposure to a convalescent patient. 

„ 6. „ 18 days after commencement of exposure to 

a convalescent patient. 

„ 7. Eruption 16 days after commencement of exposure. 

»* w* >» J-O tt if )f 

In all, therefore, we have ten cases in which the date at 
which the exposure to infection commenced is known. To 
show the relative frequency on the various days they may be 
arranged thus : 

13 7 

26 12 5 

A A A 

Days 13 14 15 16 

In Case 26 it appears to be possible that infection may 
have occurred a day earlier since the boys were at the same 
school, though no communication is known to have taken 
place between them. It cannot, therefore, be affirmed from 
these cases that the incubation period of varicella is ever less 
than fourteen days. 

In attempting to ascertain the longest interval which may 
elapse between exposure and the appearance of the rash in 
the person exposed, some evidence may also be obtained from 
cases in which the date at which exposure ceased is known ; 
these, fifteen in number, are collected in Table II. In none 
of these cases did the interval exceed nineteen days, which 
may therefore be fairly taken to be the maximum period of 
incubation. 

Table II. — Oases in which eoojposure ceased at a "known date. 





6 


15 


30 


3 


14 


A 


A 


A 


17 


18 


19 





Interval to 


No. of 


Initial 


Rash? 


case. 
4 


symptoms. 

• 


12 


9 




13 


18 




13 


11 




14 


10 




15 


16 




15 



Attended infected school. 
At school in which a case, isolated as soon as 
recognised, occurred. 

» »» n 

It *» n 

»i t> tt 

9> ft »9 



214 



i 






Varicella. 




Inters 

A 


■Ito 
lUsh. 




No. of 


InituJ 




ease. 


qnaptooii. 






17 




15 


At ichool in which a case, isolated ai toon as 
reeogmfed, occurred. 


19 




16 


f» »t n 


20 




16 


»f tf >» 


21 




16 


»» *f »9 


28 




16 


M f» *> 


24 




16 


ft »» » 


22 




17 


>» >» »9 


1 




19 


Attended infected school. 


25 




10 


At a school in which a case, iiolated as soon 
as recogmsed, occnrred. 



In all the cases in Table II except Cases 1 and 4 the 
infector was isolated as soon as the rash appeared on him. 
In certain other cases the exposure was continuous^ but the 
date of the appearance of the rash in the infector and in the 
person infected were noted. In 4 cases (Cases 27^ 31^ 32^ 
33) the interval was thirteen days ; in 3 cases (Cases 28, 29, 
35) it was fourteen days ; in 2 cases (Cases 5 and 7) it was 
sixteen days ; in 3 cases (Cases 3, 6, and 34) it was eighteen 
days; and in 1 case (Case 2) it was nineteen days. These 
cases, combined with those in Table U, are arranged below ; 
the table shows the intervals between the appearance of the 
eruption in the infector and in the person infected. 









Table III 


• • 














24 










83 






28 










32 






21 










31 


85 




20 










27 


29 


17 


19 




84 


25 




18 


28 


16 


7 




6 


2 




9 


11 


10 


5 


22 


8 


1 




A 


A 


A 


A 


A 


A 


A 


Days 


18 


14 


15 


16 


17 


18 


19 



There is also Dr. Whitelegge's statement that in his ex- 
perience the interval between the first and second cases in 
a household is usually fourteen days, and his further obser- 
vation that where exposure is not free at first the interval is 
often longer. In the outbreak recorded by Dr. Clement 
Dukes, as originated by the boy E. (Cases 12 to 15), the ex- 
posure must have been for a period of less than twenty-four 
hours. The 4 cases apparently infected by B. were at^cked 
fourteen, fifteen, nineteen, and nineteen days later respec- 
tively. It will be noted that the boy first attacked appears 



Varicella. 215 

to have been in more intimate relation with E. than the other 
three. 

In one of Dr. Churchill's cases the period may have been 
as short as twelve days, but may have been with equal pro- 
bability longer. The extremely short period suggested by the 
case of the housemaid in Dr. Cayley^s case is probably in- 
correct, the other alternative suggested being possibly the 
true explanation. 

Pebiod of Infectiousness. 

The cases collected do not supply much evidence on this 
head. Dr. Clement Dukes's cases, notably Cases 12, 13, 14, 
15, 25, and 26, show that the disease is infectious at an early 
stage — in fact, practically as soon as its nature can be recog- 
nised. Cases 5 and 6 afiEord evidence that the disease may 
be derived from a convalescent patient, and Case 30 appears 
to indicate that the infection may be conveyed by a person 
who does not suffer; Case 8, also, is probably an instance 
of the same occurrence. 

Conclusions. 

(1) The incubation period of varicella is usually fourteen 
days, but may be a day less or four or five days more. 

(2) The infection may be derived from a patient at least as 
soon as the rash appears. « 

(3) A convalescent patient may convey the infection to 
others. 

(4) The infection may probably be conveyed in clothes. 



216 Varicella, 



CASES. 

Ccues Ito 4i. 
Commnnicated by Dr. Chubohill. 

A bo J, affed 6 (Case 1), ceased to go to school on Febraary 24; on 
February 28 he had pneumonia, and on March 13 chicken-pox came 
out, nineteen days aftier ceasing to attend school. The boy's mother 
came to nurse him from March 3 to March 25. The mother was 
accompanied by an infant (Case 2), on whom the first spots of chicken- 
pox appeared April 1. A young sister (due 3) who visited the first 
patient on March 23, and returned to London with the rest of the 
family on March 25, had first spots on April 11 (eighteen days after 
commencement of exposure). 

A boy, aged 3 or 4 (Case 4), attended the same school for the last 
time on March 11, and had chicken-pox on March 23 (twelve days after 
ceasing to go to school). 

Cases 5 and 6. 
Communicated by Dr. Beavak Baxb. 

A boy who had had chicken-pox at a school returned home, several 
hundred miles, when convalescent ; he arrived on December 20, 1877, 
and on January 3, 1878, a brother (Case 5) had premonitory symptoms ; 
the eruption began to appear on the night of J anuary 5 (eruption six- 
teen days after commencement of exposure). Another brother (Case 6) 
returned to the infected house on December 22, and remained until Janu- 
ary 2 ; the rash appeared on January 9 (eighteen days after commence- 
ment of exposure). 

Cases 7 and 8. 

Commnxucated by Dr. Caylby. 

A girl was admitted into the Middlesex Hospital with varicella on 
January 14, 1878 ; on January 30 the physician's assistant (Case 7) who 
had charge of the case was attacked, liicubation not more than six- 
teen days. On February 4 the housemaid (Case 8) who waited in his 
room, but who had not been brought in contact with the first case, 
was attacked— probable contagiousness during period of incubation. 
Infection may, however, have l^en conveyed by clothes. 

Cased. 

Communicated by Dr. Abthttb Stedicak. 

Four cases occurred in a school on May 12 ; their source was not 
traced. The next case (Case 9) occurred May 25 (thirteen days after the 
first cases). 

Cases 10 to 26. 

Communicated by Dr. Clbmbnt Ditxes. 

Two cases occurred in a master's house in 1874, on March 7 and 8 
respectively ; the next case (Case 10) in that house was attacked on 
March 22 (fourteen days after the last and fifteen after the first of the 
two. cases). 



Vuricella. 217 

Two cases occurred in another bouse on March 10, 1874 ; the next 
case (Case 11) in that house occurred on March 24 (fourteen days after). 

A boy, E., returned to school on September 12, 1877, and sat next to 
fi. for two hours ; next day E. was found to have varicella, and was 
removed from the house at once. H. (Case 12) had eruption September 
26 (fourteen days after exposure). Another case (Case 13) occurred in 
the same house on September 27 (fifteen days), and two more (Causes 
14 and 15) on October 1 (nineteen days). 

On November 9, 1878, a boy, D., had vaiicella. The next case in this 
house (Case 16) occurred on November 24; another boy (Case 17), 
who belonged to another house, but sat next but one to D. in form, 
was attacked on the same day (fifteen days). 

On November 15, 1880, a case occurred in Mr. E.'s house, and another 
on the following day; the next case (Case 18) occurred on Novem- 
ber 29 (thirteen and fourteen days after) ; 3 cases (Cases 19, 20, 21) on 
December 2 (sixteen or seventeen days), and one (Case 22) on Decem- 
ber 3 (seventeen or eighteen days). 

Two cases occurred on March 2 and 3 respectively in Mr. T. W.'s 
house ; the next case (Case 23) in that house occurred on March 19 
(sixteen or seventeen days after), but on the previous day a boy 
(Case 24) living in a different house, but in the same form with the 
earliest case, had the disease (sixteen days). 

On March 12, 1886, 0. was found to have varicella, and was isolated. 
D. (Case 25), who had been in the same study with 0. on that day, was 
attacked on March 31 (nineteen days). 

B. returned to school on May 14, 1886, and next day spots were 
found on him; there had been cases at his home. P. (Case 26), who 
was with B. on May 15, was attacked on May 28. 

Cases 27 to 35. 

Commanicated by Dr. Sqitibe (also published in his Bssays in Preventive 

Medicine, p. 78). 

A girl attending a day school had a spot on her lip on May 30, and 
next day other spots, recognised as variceUa ; the height of the disease 
was on June 1 and 2, when she remained in bed. Her younger brother 

SCase 27), who occupied the same bedroom, was ill with chicken-pox on 
Tune 12, thirteen days after his sister had the first spot, and ten after 
the disease was at its height in her. Two elder brothers (Cases 28 and 
29) had the disease on June 13 ; '' the interval in these cases was pro* 
bably twelve days." 

A girl, aged 3 (nearly), was visited on November 29 or 30 by a nurse 
attendinfi^ upon a child with chicken-pox. This girl (Case 30) had 
" signs of chicken-pox " on December 14, fourteen or fifteen days after 
the visit of the nurse. The symptoms were well marked on Decem- 
ber 16. The brother of Case 30, aged 7 (Case 31), at home with her, 
was taken ill on December 27, thirteen days after his sister had the 
first symptoms, and had the full eruption on December 28. 
. A boy, aged 7, sickened with chicken-pox on April 13, and was ill 
with it on April 14 and 15. His two elder brothers returned home 
from school on April 10, and were much with him up to the time of his 
illness. Both showed slight signs of the illness on April 23, ten days 
after the initial symptoms in the younger boy. One of them, the 



218 VaHeella. 

younffer (Case 32), had hic^h feyer and fall eraption on April 26. 
Hie elder, aged 16 {Case 33), who is known to have had the disease in 
infancy, showed signs of rash on April 26, but the spots aborted, fad* 
ing on the third or fourth days without bcKSoming yesicular. 

A boy, aged 5^, had the first spots of varicella on March 8, and the 
full eruption on March 9 and 10. His younger brother {Case 34), 
aged 2, showed spots of yaricella in great numbers on March 26, 
eighteen da^s after his brother's rash began. This child had begun 
with whooping-cough about March 10, and Dr. Squire suggests that the 
presence of the whooping-cough led to a prolongation of the incubation 
period of the varicella. An infant {Case 35), aged 4 months, began to 
suffer from varicella on March 22, fourteen days after the elder brother 
began to have the rash. It had whooping-cough about a month later. 

Commanicated by Br. Abthttb Whitblb»ox, Medical Officer to the West 

Hiding Coonty Council. 

" I have seen many cases in which the interval between first and 
second cases in household was almost exactly fourteen days, and I have 
come to regard this as the normal and usual interval. Sometimes it 
has been thii'teen days, e. g, January 1—14, and of course frequently 
longer than fourteen when exposure was not free at first." 

Case 36. 
Dr. Mfbchisok (7Vans<tcHons, vol. xi, p. 240). 

" I find among my notes only one case {Case 36) showing the duration 
of the incubation period of varicella; in that case it was eleven days. 
Most authorities make it longer than this." 



WHOOPING-COUGH. 

THE attempt to determine with any precision the true incu- 
bation period of whooping-cough must always be sur- 
rounded with great diflSculty. The duration of the catarrhal 
stage^ during which the symptoms are not characteristic^ is 
uncertain, though as a rule it occupies, probably, about a week ; 
in many cases the onset is insidious, while in others of a more 
severe type the presence of intercurrent pneumonia at an 
early date delays the appearance of the paroxysmal cough and 
whoop for days or weeks. The study of a large number of 
cases would be necessary in order to eliminate the various 
sources of error, and this is not here possible, since the cases 
sent to the Committee are few in number. It has seemed 
advisable, therefore, to do little more than place on record the 
histories, in the hope that further material may be accumulated 
in the course of time. 

The cases, so far as they go, support the opinion that the 
incubation period varies a good deal. Thus in Case 1 the 
catarrh began five days and the whoop eight days after the 
commencement of exposure to infection, whereas in Cases 7 
and 8 the earliest symptoms of catarrh were not observed 
until thirteen days after the single exposure to which infection 
was attributed. Case 6 points to a short period of incubation 
— about a week. 

Case 3 is an example of infection derived from a patient in 
the early stage. Case 5 is an example of infection conveyed 
by persons not themselves affected, but in intimate relation 
with sufferers. In this case, and probably also in the epidemic 
on board the Oasis described by Dr. W. H. Pearse, it seems 
reasonable to assume that the infective material was carried 
in fomites. 



220 Whooping'Cough. 



CASES. 

Ccues 1 to 6. 

Communicated by Dr. W. SQnxB (also published in his E$»ay9 in Preventive- 

Medicine, p. 82). 

Case 1. — A eirl, aged 12, was brought home to a family, some 
members of which had whooping-cough, on July 25 ; she had spasmodic 
cough with bronchial rdles on July 30, and whooped on August 2 — 
eight days after her return. 

Towards the end of August the jrounger children of a family 
resident in London began to associate, in the garden of the square in 
which they resided, with the children of another family which had 
returned from the sea-side with whooping-cough. After September 2 
there was no farther communication between the families. One of the 
children, aged 6 (Case 2), of the family first mentioned began to suffer 
from cdush, which had become frequent by September 7, aud during 
the next few days all the younger children began to cough. An elder 
sister, aeed 15 {Case 3), who had not been in the gardens but had been 
a good deal with Case 2, was sent away to an aunt's house on Sep- 
tember 9. She began to have a cough on September 13 (four days 
after leaving home), and the nature of her cough was distinct on 
September 20 (eleven days after leaving home). Her cousin, 8 years 
old {Case 4), residing in the house, began to have a cough and to be ill 
soon after, and by September 30 the character of the cough was pro« 
nounced (twentv-one days after arrival of Case 3^ and ten after her 
cough became characteristic). 

Vase 5. — ^A boy, aged 2, was visited on November 20 by friends who 
had a child at home with whoopine-coueh. The boy coughed on 
November 24, and became seriously ul wiui pneumonia on November 
28. He had recovered from the pulmonary complication on December 
8, but the cough persisted, and he whooped on December 15. (His 
illness began four days after exposure to mediate infection, but the 
whoop was not noticed until three weeks later.) 

Case 6. — A child bom on February 10, the day on which it was first 
suspected that two children in the house had whooping-cough, began 
to pine after the first week, and to have difi&culty in taking the breast ; 
on February 24 there was no doubt that it had whooping-cough, of 
which it died a few days later. 

Cases 7 and 8. 

Communicated by Mr. F. B. Humphrey, London, N.W. 

W. H. and G. H. returned from the sea-side on July 23. On July 29 
they played with some children for three quarters of an hour in the 
afternoon. These children were suffering at the time from a severe 
cough, with sickness when they coughed, relaxed throats, &c., but did 
not whoop till a week or two afterwards when at the sea- side. This 
was the only occasion on which the children met. On August 11 
W. H. and G, H. showed signs of catarrh. The younger {Case 7) was 
a girl aged 18 months, the elder {Case 8) a boy aged 2 years 9 months. 
The younger one's trouble began with puffy face, swollen eyes, and 



Whooping-cough. 221 

^eat languor ; the elder's with raiining at the nose. The disease ran 
a mild coarse. In six weeks from the onset thej were sent away to the 
sea-side for a change, returning in fourteen days with coueh, but 
having lost the whoop. This was the only opportunity the cnildren 
liad of getting the disease. 

Commanicated by Dr. W. H. Pbabsb, Plymoath. 

Ship Oasis, Calcutta to Demerara, with 446 souls, including 43 
children (1 to 10 years) and 33 infants (under 1 year) ; embarked 
September 2, 1865. On October 25, lat. 27^ south, occurred the first 
case of whooping-cough. The case had ailed since October 21. Oases 
followed on October 27 (1 case), 29 (1), November 9 (1), 12 (1), 15 (1), 
17 (1), 29 (2) ; December 11 (1). (First symptoms in the first case on 
fiftieth day after leaving port.) 

Ship bougoumontt Plymouth to Adelaide, 1866, sailed June 9 
with 336 souls, including 46 children and 5 infants. When sixty-six 
days out, on August 14, uht. 39^ south, long. 2^ east, the first and only 
case like whoopine-cough occurred. 

Ship LiverpooT, Calcutta to Trinidad, sailed September 7, 1867, 
with 532 souls, including 35 children and 9 infants. On October 3 a 
case like whooping-cough showed ; none followed. 



INDEX OF NAMES. 



••o»- 



AiBT, Dr. H. 

Diphtheria, 1, 21, 23, 41, 42, 49, 
50 

Scarlet fever (milk), 171 

Smallpox, 196 
Allbk, Dr. J. W. 

Measles, 100 
Akdebsov, Dr. Fobd 

Scarlet fever, 152 
AsxBTBOKO, Dr. G. W. 

Measles, 98 
Abvbtboitg, Dr. H. £. 

Measles, 97 

Smallpoz, 191 
Abxstboitg, Dr. H. G. 

Measles, 98 

Kubeola, 128 



Baxer, Surgeon (A. M. D.) 

Measles, 100 
Ballabd, Dr. 

Enteric fever, 64, 65, 67, 68 
Babkbb, Mr. W. J. Towkbbkd 

Inflnenza, 86 
Babnbs, Dr. E. G. 

Enteric fever, 77 

Scarlet fever, 153 
Babbt, Dr. P. W. 

Enteric fever, 72 
Battahb, Mr. J. Scott 

Scarlet fever, 158 
Bayitbs, Dep. Insp.-Gen., W. W. 

Scarlet fever, 152 
Bbbt, Dr. Fbbd. A. 

Mumps, lis 

Smallpox, 189 
Bibdwood, Dr. B. A. 

Smallpox, 181, 185, 191—194 
Bibt, Dr. G. 

Mumps, 117 



Blaxall, Dr. 

Diphtheria, 20, 23, 24, 26, 29, 80, 
48 

Enteric fever, 69, 70, 71 

Scarlet fever, 162 
Boobbteb, Dr. Ph. 

Enteric fever, 76 

Smallpox, 190 
BOZALL, Dr. B. 

Scarlet fever, 154, (puerperal) 175 
Bbistowb, Dr. J. S., F.B.S. 

Bubeola, 130 
Bboadbbztt, Dr. W. H. 

Mumps, 113 
BXTOHANAV, Sir Gbobob, F.B.S. 

Enteric fever, 63, 64 

Scarlet fever, 158, (milk) 171 



Cambbon, Dr. Spottibwoodb 

Scarlet fever, 152 
Cabpektbb, Dr. Gbobgb 

BnbeoU, 128 
Cabb, Dr. J. W. 

Measles, 98 
Cabbt, Dr. Ebwabd 

Influenza, 85 
Gatlby, Dr. 

Mumps, 117 

Varicella, 216 
CHOPnrsT, Dr. (M^d-M(^.) 

Mumps, 118 
Ceuboeill, Dr. 

Varicella, 216 
Clabkb, Dr. Adahb 

Measles, 99 

Mumps, 117 
Clabbb, Brigade-Surgeon Albbbd 

Diphtheria, 19 
CoLCLOuaH, Mr. Fbavk 

Vaccinia and variola, 187, 198 



224 



Index of Names. 



CotrLnr0, Mr. H. 

Scarlet fever, 152 
CULLIVOWOBTH, Dr. C. J. 

Influenza, 85 

Dbskbtb, M. DAKauY dbs 

Influenza, 87 
DowHBS, Dr. 

Diphtheria, 25 
DmcB, Dr. B. 

Mumps, 118 
DuEBS, Dr. Clbicbvt 

Measles, 100 

Mumps, 114 

Buheola, 125 

Scarlet fever, 156 

Yarioella, 216 

Eyavb, Dr. F. M. 
Smallpox, 189 

FBBTOir, Dr. Mabk 
Scarlet fever, 156 

GOBKALL, Dr. J. H. 

Measles, 102 
Gbbsbwbll, Dr. 

Diphtheria, 81, 32, 34— 36, 88 
Gbbwoock, Dr. J. B. 

Enteric fever, 76 

Haig-Bbowk, Dr. C. W. 

Mumps, 117 

Kuheola, 130 

Scarlet fever, 158 
Habbibs, Dr. Gwynkb 

Enteric fever, 63 
Habvby, Mr. W. 

Enteric fever, 74 
Hbndbbsov, Dr. G. C. 

Measles, 103 
Hbwbb, Mr. 

Influenza, 79 
Hill, Dr. A. 

Scarlet fever, 155 
Hill, Mr. Lbwin 

Mumps, 113 
HOAB, Dr. C. E. 

Mumps, 114 
HosTB, Dr. d' 

Influenza, 87 
HuxPHBBY, Dr. F. B. 

Measles, 101 

Scarlet fever, 156 

Whooping-cough, 221 



JOLLTB, Dr. F. W. 
Scarlet fever, 155 

LOAITB, Dr. J. 

Smallpox, 191 
Low, Dr. Bbucb 

Diphtheria, 19, (milk) 45 

Scarlet fever, 153 
LOWNDBB, Dr. 

Measles, 97 
Lush, Dr. W. Vattdbbt 

Measles, 101 

Mackbvzib, Dr. Stbfhbk 

Influenza, 80 
MiDDLBTOir, Dr. G. S. 

Enteric fever, 76 
MUBOHisov, the late Dr. 

Enteric fever, 77 

Scarlet fever, 165, (milk) 17 

Smallpox, 198 

Varicella, 218 
MUBPHT, Dr. H. HOWABD 

Influenza, 82 
MUBFHT, Mr. Shibley 

Scarlet fever, 151 

Nbwm AH, Dr. W. 
Measles, 101 

O'ComnsLL, Dr. P. 

Measles, 101 
Ogle, Dr. W. 

Diphtheria, 21 

Paqb, Dr. 

Enteric fever, 73 

Scarlet fever, 162 
Pabkivbon, Dr. C. H. Watts 

Measles, 98 
Pabbonb, Dr. H. Fbankliv 

Diphtheria, 22, 23, 27, 28, 43, 46— > 
49, 51, 52 

Enteric fever, 73, 74 

Influenza, 87 

Scarlet fever, 161, 162 
Patmobb, Mr. Cotentby 

Influenza, 80 
Peabsb, Dr. Fbbd. 

Measles, 99 

Mumps, 117 

Scarlet fever, 155 
Peabbb, Dr. W. H. 

Measles, 103 

Whooping-cough, 221 



Index of Names. 



225 



POWEE, Mr W. H. 

Diphtheria, 20, 22, (milk) 25, 39 
Enteric fever, 64, 70, 72 
Scarlet fever (milk), 173 

QniKTON, Dr. R. F. 
Inflaenza, 80 

Bapoltffe, Mr. Nbtten 

Enteric fever, 63, 64 
Bailton, Dr. T. C. 

Rubeola, 128 
Bake, Dr. Beayan 

Varicella, 216 
Batcltffe-Gaylabd, Dr. 

Scarlet fever, 154 
BieBEy, Dr. GEOBGhE 

Smallpox, 189 
BoBivsoN, Dr. Wm. 

Smallpox, 195 

Shea, Dr. 

Scarlet fever (milk), 171 
Simpson, Dr. 

Diphtheria, 34, 36 
SnrcLAiB, Dr. Jab. E. 

Influenza, 85 
Smith, Dr. C. B. 

Measles, 97 
Speab, Mr. John 

Diphtheria, 31, 43, 46, 47 

Enteric fever, 74, 75 
Spencbb, Dr. J. H. 

Scarlet fever, 155 
Squibe, Dr. W. 

Diphtheria, 64 

Influenza, 86 

Measles, 104 

Mumps, 119 

Bubeola, 129 

Scarlet fever, 165 

Varicella, 217 

Whooping>coagh, 220 
Statham, Dr. Hugh W. 

Scarlet fever, 158 
Stedmak, Dr. A. 

Measles, 98 

Mumps, 118 

Bubeola, 130 



Stbdman, Dr. A. {continued) 

Smallpox, 189 

Varicella, 216 
Stetensok, Dr. Thos. 

Smallpox, 190 
Stbbtton, Dr. 

Measles, 102 
Sweeting, Mr. R. D. R. 

Diphtheria, 32, 52, 53 

Thobne-Thobne, Dr. R. 

Enteric fever, 63, 65—67, 69 
Thitbnam, Dr. F. W. 

Measles, 102 
Tibbles, Dr. W. 

Influenza, 79 
Tonge-Smith, Dr. W. 

Scarlet fever, 163 
Ttjbneb, Mr. Geobge 

Diphtheria, 37, 38 

Vachell, Dr. 
Measles, 101 

Walpobd, Dr. Ed. 

Smallpox, 195 
Weayeb, Dr. James 

Diphtheria, 19 
Welch, Dr. G. S. 

Measles, 99 
Whitblbggb, Dr. Abthfb 

Diphtheria, 54 

Scarlet fever, 157 

Smallpox, 186, 196 

Varicella, 218 
Whitley, Dr. 

Enteric fever, 66 
Wilkinson, Dr. Fbed. 

Measles, 99 

Smallpox, 190 
WiLLoocKS, Dr. Fbed. 

Rubeola, 128 
Williams, Dr. Dawson 

Influenza, 86 
Wilson, Dr. G. T. 

Scarlet fever, 152 
Wilson, Dr. J. H. 

Influenza, 85 



FBINTKD BT ADLABD AND SON, 
BABIHOLOMEW CL08B, B.C., ASD 20, HANOVBB SQUABB, W. 



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